Appendicitis in children in primary care: improving the diagnostic process

Recognizing appendicitis in children is a diagnostic challenge for General Practitioners (GPs). In this thesis, we aimed to improve the diagnostic process in primary care. Extensive research in secondary care has yielded clinical decision rules and blood tests like C-reactive protein (CRP), but their applicability in primary care remains uncertain. This is due to differences in disease severity and differential diagnosis.
Four studies were conducted to address this knowledge gap. A Delphi survey with 22 GPs resulted in a consensus list, containing important actions and documentation during the consultation. In the second study, a cohort study within the IPCI database, appendicitis went unrecognized in nearly 20% of cases initially and about two-third of GP referrals were negative. Individual symptoms and signs demonstrated limited diagnostic value, with signs having more diagnostic value than symptoms. The third study, also within the IPCI database, demonstrated CRP's added value to clinical features. After 48 hours of symptoms duration, increased sensitivity of CRP was observed. The final cohort study resulted in a validated clinical prediction rule for appendicitis in primary care, facilitating risk stratification. The proposed diagnostic strategy recommends watchful waiting for low-risk cases, CRP testing with reassessment for medium-risk cases, and immediate referral for high-risk cases.
In conclusion, the study suggests replacing pattern recognition with a clinical prediction rule for a more feasible and standardized diagnostic approach in primary care. The proposed strategy, if validated through further research, could improve the diagnostic process, minimizing unnecessary referrals while ensuring timely referral for children with appendicitis.