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Importance: Diagnostic delays are common in the emergency department (ED) and may predispose to worse outcomes., Objective: To evaluate the association of annual pediatric volume in the ED with delayed diagnosis., Design, Setting, and Participants: This retrospective cohort study included all children younger than 18 years treated at 954 EDs in 8 states with a first-time diagnosis of any of 23 acute, serious conditions: bacterial meningitis, compartment syndrome, complicated pneumonia, craniospinal abscess, deep neck infection, ectopic pregnancy, encephalitis, intussusception, Kawasaki disease, mastoiditis, myocarditis, necrotizing fasciitis, nontraumatic intracranial hemorrhage, orbital cellulitis, osteomyelitis, ovarian torsion, pulmonary embolism, pyloric stenosis, septic arthritis, sinus venous thrombosis, slipped capital femoral epiphysis, stroke, or testicular torsion. Patients were identified using the Healthcare Cost and Utilization Project State ED and Inpatient Databases. Data were collected from January 2015 to December 2019, and data were analyzed from July to December 2023., Exposure: Annual volume of children at the first ED visited., Main Outcomes and Measures: Possible delayed diagnosis, defined as a patient with an ED discharge within 7 days prior to diagnosis. A secondary outcome was condition-specific complications. Rates of possible delayed diagnosis and complications were determined. The association of volume with delayed diagnosis across conditions was evaluated using conditional logistic regression matching on condition, age, and medical complexity. Condition-specific volume-delay associations were tested using hierarchical logistic models with log volume as the exposure, adjusting for age, sex, payer, medical complexity, and hospital urbanicity. The association of delayed diagnosis with complications by condition was then examined using logistic regressions., Results: Of 58 998 included children, 37 211 (63.1%) were male, and the mean (SD) age was 7.1 (5.8) years. A total of 6709 (11.4%) had a complex chronic condition. Delayed diagnosis occurred in 9296 (15.8%; 95% CI, 15.5-16.1). Each 2-fold increase in annual pediatric volume was associated with a 26.7% (95% CI, 22.5-30.7) decrease in possible delayed diagnosis. For 21 of 23 conditions (all except ectopic pregnancy and sinus venous thrombosis), there were decreased rates of possible delayed diagnosis with increasing ED volume. Condition-specific complications were 11.2% (95% CI, 3.1-20.0) more likely among patients with a possible delayed diagnosis compared with those without., Conclusions and Relevance: EDs with fewer pediatric encounters had more possible delayed diagnoses across 23 serious conditions. Tools to support timely diagnosis in low-volume EDs are needed.

Importance: Delayed diagnosis of appendicitis is associated with worse outcomes than timely diagnosis, but clinical features associated with diagnostic delay are uncertain, and the extent to which delays are preventable is unclear., Objective: To determine clinical features associated with delayed diagnosis of pediatric appendicitis, assess the frequency of preventable delay, and compare delay outcomes., Design, Setting, and Participants: This case-control study included 748 children treated at 5 pediatric emergency departments in the US between January 1, 2010, and December 31, 2019. Participants were younger than 21 years and had a diagnosis of appendicitis., Exposures: Individual features of appendicitis and pretest likelihood of appendicitis were measured by the Pediatric Appendicitis Risk Calculator (pARC)., Main Outcomes and Measures: Case patients had a delayed diagnosis of appendicitis, defined as 2 emergency department visits leading to diagnosis and a case review showing the patient likely had appendicitis at the first visit. Control patients had a single emergency department visit yielding a diagnosis. Clinical features and pARC scores were compared by case-control status. Preventability of delay was assessed as unlikely, possible, or likely. The proportion of children with indicated imaging based on an evidence-based cost-effectiveness threshold was determined. Outcomes of delayed diagnosis were compared by case-control status, including hospital length of stay, perforation, and multiple surgical procedures., Results: A total of 748 children (mean [SD] age, 10.2 [4.3] years; 392 boys [52.4%]; 427 White children [57.1%]) were included in the study; 471 (63.0%) had a delayed diagnosis of appendicitis, and 277 (37.0%) had no delay in diagnosis. Children with a delayed diagnosis were less likely to have pain with walking (adjusted odds ratio [aOR], 0.16; 95% CI, 0.10-0.25), maximal pain in the right lower quadrant (aOR, 0.12; 95% CI, 0.07-0.19), and abdominal guarding (aOR, 0.33; 95% CI, 0.21-0.51), and were more likely to have a complex chronic condition (aOR, 2.34; 95% CI, 1.05-5.23). The pretest likelihood of appendicitis was 39% to 52% lower in children with a delayed vs timely diagnosis. Among children with a delayed diagnosis, 109 cases (23.1%) were likely to be preventable, and 247 (52.4%) were possibly preventable. Indicated imaging was performed in 104 (22.0%) to 289 (61.3%) children with delayed diagnosis, depending on the imputation method for missing data on white blood cell count. Patients with delayed diagnosis had longer hospital length of stay (mean difference between the groups, 2.8 days; 95% CI, 2.3-3.4 days) and higher perforation rates (OR, 7.8; 95% CI, 5.5-11.3) and were more likely to undergo 2 or more surgical procedures (OR, 8.0; 95% CI, 2.0-70.4)., Conclusions and Relevance: In this case-control study, delayed appendicitis was associated with initially milder symptoms but worse outcomes. These findings suggest that a majority of delayed diagnoses were at least possibly preventable and that many of these patients did not undergo indicated imaging, suggesting an opportunity to prevent delayed diagnosis of appendicitis in some children.

Importance: Pneumonia is a leading cause of morbidity and mortality in children. It is important to identify the clinical symptoms and physical examination findings associated with pneumonia to improve timely diagnosis, prevent significant morbidity, and limit antibiotic overuse., Objective: To systematically review the accuracy of symptoms and physical examination findings in identifying children with radiographic pneumonia., Data Sources and Study Selection: MEDLINE and Embase (1956 to May 2017) were searched, along with reference lists from retrieved articles, to identify diagnostic studies of pediatric pneumonia across a broad age range that had to include children younger than age 5 years (although some studies enrolled children up to age 19 years); 3644 unique articles were identified, of which 23 met inclusion criteria., Data Extraction and Synthesis: Two authors independently abstracted raw data and assessed methodological quality. A third author resolved disputes., Main Outcomes and Measures: Likelihood ratios (LRs), sensitivity, and specificity were calculated for individual symptoms and physical examination findings for the diagnosis of pneumonia. An infiltrate on chest radiograph was considered the reference standard for the diagnosis of pneumonia., Results: Twenty-three prospective cohort studies of children (N = 13 833) with possible pneumonia were included (8 from North America), with a range of 78 to 2829 patients per study. The prevalence of radiographic pneumonia in North American studies was 19% (95% CI, 11%-31%) and 37% (95% CI, 26%-50%) outside of North America. No single symptom was strongly associated with pneumonia; however, the presence of chest pain in 2 studies that included adolescents was associated with pneumonia (LR, 1.5-5.5; sensitivity, 8%-14%; specificity, 94%-97%). Vital sign abnormalities such as fever (temperature >37.5°C [LR range, 1.7-1.8]; sensitivity, 80%-92%; specificity, 47%-54%) and tachypnea (respiratory rate >40 breaths/min; LR, 1.5 [95% CI, 1.3-1.7]; sensitivity, 79%; specificity, 51%) were not strongly associated with pneumonia diagnosis. Similarly, auscultatory findings were not associated with pneumonia diagnosis. The presence of moderate hypoxemia (oxygen saturation ≤96%; LR, 2.8 [95% CI, 2.1-3.6]; sensitivity, 64%; specificity, 77%) and increased work of breathing (grunting, flaring, and retractions; positive LR, 2.1 [95% CI, 1.6-2.7]) were signs most associated with pneumonia. The presence of normal oxygenation (oxygen saturation >96%) decreased the likelihood of pneumonia (LR, 0.47 [95% CI, 0.32-0.67])., Conclusions and Relevance: Although no single finding reliably differentiates pneumonia from other causes of childhood respiratory illness, hypoxia and increased work of breathing are more important than tachypnea and auscultatory findings.

Importance: Advanced diagnostic imaging is commonly used in the evaluation of suspected appendicitis in children. Despite its inferior diagnostic performance, ultrasonography (US) is now preferred to computed tomography (CT) owing to concerns about ionizing radiation exposure. With changes in imaging modalities, the influence on outcomes should be assessed., Objectives: To review trends in the use of US and CT for children with appendicitis and to investigate simultaneous changes in the proportions of negative appendectomy, appendiceal perforation, and emergency department (ED) revisits., Design, Setting, and Participants: We reviewed the Pediatric Health Information System administrative database for children who presented to the ED with the diagnosis of appendicitis or who underwent an appendectomy in 35 US pediatric institutions from January 1, 2010, through December 31, 2013., Main Outcomes and Measures: We studied the use of US and CT for trends and their association with negative appendectomy, appendiceal perforation, and 3-day ED revisits., Results: Our investigation included 52,153 children with appendicitis. Use of US increased 46% (from 24.0% in 2010 to 35.3% in 2013; absolute difference, 11.3%; adjusted test for linear trend, P = .02), whereas use of CT decreased 48% (from 21.4% in 2010 to 11.6% in 2013; absolute difference, -9.8%; adjusted test for linear trend, P < .001). The proportion of negative appendectomy declined during the 4-year study period from 4.7% in 2010 to 3.6% in 2013 (test for linear trend, P = .002), whereas the proportion of perforations (32.3% in 2010 to 31.9% in 2013) and ED revisits (5.6% in 2010 and 2013) did not change (adjusted tests for linear trend, P = .64 and P = .84, respectively)., Conclusions and Relevance: Among children with suspected appendicitis, the use of US imaging has increased substantially as the use of CT has declined. Despite the increased reliance on the diagnostically inferior US, important condition-specific quality measures, including the frequency of appendiceal perforation and ED revisits, remained stable, and the proportion of negative appendectomy declined slightly.