The Diagnosis of Appendicitis in Children: Outcomes of a Strategy Based
on Pediatric Surgical Evaluation
Ann M. Kosloske, MD, MPH*‡储; C. Lance Love, MD*; James E. Rohrer, PhD§; Jane F. Goldthorn, MD*‡储;
and Stuart R. Lacey, MD*‡储
ABSTRACT. Objective. To determine the accuracy of
a protocol for diagnosis of appendicitis in children based
on clinical evaluation by a pediatric surgeon with selec-
tive use of diagnostic imaging studies. We performed
this study because 1) current reports in the medical, pe-
diatric, emergency medical, and surgical literature advo-
cate imaging, particularly computed tomography (CT), as
the gold standard for diagnosis of appendicitis, and 2)
the value of pediatric surgical evaluation early in the
management of the child with possible appendicitis has
rarely been emphasized.
Methods, Design, Setting, and Participants. Retro-
spective review of 356 children (mean age: 9.6 years;
range: 1–18 years) referred to a regional pediatric surgical
center for possible appendicitis from 1999 through 2001.
Interventions. Initial pediatric surgical evaluation
consisted of history, physical examination, white blood
cell count, differential count, and urinalysis. Children
diagnosed with appendicitis underwent appendectomy
without additional studies; those with equivocal find-
ings received intravenous fluids, rest, and reevaluation
after 4 to 6 hours. Imaging was used selectively by the
pediatric surgeon.
Outcome Measures. Sensitivity, specificity, positive
predictive value, negative predictive value, and accuracy
of the protocol based on final diagnoses; rate of appen-
diceal perforation; and rate of negative appendectomy.
Results. Of 356 children evaluated for appendicitis,
220 (62%) had an appendectomy. Two-hundred nine
(95%) had histologically proven appendicitis, and 11 (5%)
had a normal appendix. Of the 209 children with appen-
dicitis, 139 (66%) had acute appendicitis, 34 (16%) had
advanced appendicitis without perforation, and 36 (17%)
had advanced appendicitis with perforation. Appendec-
tomy was performed after initial evaluation in 195 (89%)
of the 220 children and after a period of supportive care
and observation in 25 (11%) of 220. One hundred thirty-
six children (38%) did not have an appendectomy and
were discharged with other diagnoses. The sensitivity of
this protocol was 99%, specificity was 92%, positive pre-
dictive value was 95%, and negative predictive value was
99%. The accuracy was 97% compared with an accuracy of
82% for ultrasound alone and 90% for CT scan alone.
Conclusions. These data show that a protocol based
on clinical evaluation by a pediatric surgeon with selec-
tive use of imaging was highly accurate for the diagnosis
of appendicitis in children. Low rates of negative appen-
From the Departments of *Surgery, ‡Pediatrics, and §Health Services Re-
search, Texas Tech University, Health Sciences Center, Lubbock, Texas; and
储Covenant Children’s Hospital, Lubbock, Texas.
Received for publication Mar 3, 2003; accepted Apr 10, 2003.
Reprint requests to (A.M.K.) 1273 Par View Drive, Sanibel, FL 33957. E-mail:
akosloske@hotmail.com
PEDIATRICS (ISSN 0031 4005). Copyright © 2004 by the American Acad-
emy of Pediatrics.
Downloaded from www.aappublications.org/news by guest on July 23, 2018
dectomy (5%) and perforation (17%) were achieved with-
out the potential costs and radiation exposure of excess
imaging. Pediatrics 2004;113:29 –34; appendicitis, appen-
dectomy, pediatric surgeon, CT, computed tomography.
ABBREVIATIONS. CT, computed tomography; US, ultrasound;
WBC, white blood cell.
A
cute appendicitis is the most common surgi-
cal emergency in children and adolescents in
the United States. In 1999, an estimated
59 000 children ⬍15 years old were diagnosed with
appendicitis.1 Despite its frequency, however, the
diagnosis of appendicitis in a child is sometimes
difficult. Recent reports recommended imaging, par-
ticularly computed tomography (CT) with rectal con-
trast, as the optimal diagnostic study in both adults2
and children.3,4 One protocol used imaging (usually
both ultrasound [US] and CT scan with rectal con-
trast) in 78.5% of children with possible appendici-
tis.3,5 CT scanning was calculated as cost-effective in
children based on a negative appendectomy rate of
23%.6 Because in our west Texas pediatric surgical
practice we rely on a clinically based strategy with
selective use of imaging, and because we considered
a 23% rate of negative appendectomy to be unaccept-
ably high, we undertook the present study. We re-
viewed the outcomes of 356 children and adolescents
referred to us for possible appendicitis over a 3-year
period and calculated the accuracy of our diagnostic
strategy compared with the accuracy of imaging.
METHODS
The pediatric surgeon authors (A.M.K., J.F.G., and S.R.L.) prac-
tice in a west Texas city of 204 000 population, with a referral area
consisting of 62 primarily rural counties in west Texas and eastern
New Mexico. The total population served is 1.4 million. No other
pediatric surgeon practiced in this area during the study period.
Children and adolescents with possible appendicitis were referred
to the pediatric surgeon by a pediatrician, a family practitioner, or
an emergency department physician. Patients were treated at 2
hospitals: Texas Tech University Hospital, a 325-bed teaching
hospital with an 88-bed pediatric hospital located on one floor,
and Covenant Children’s Hospital, a 73-bed pediatric hospital that
is a separate wing of a 400-bed community hospital. The study
was approved by the institutional review boards of both hospitals.
Residents in general surgery (Post-Graduate Year 4 or Post-Grad-
uate Year 2) assisted the 3 pediatric surgeons in the diagnosis and
treatment of all patients. The “diagnostic call,” however, was
made by the attending pediatric surgeon. Radiographic studies
were performed by general radiologists at each hospital; there
were no specialty-trained pediatric radiologists at either institu-
tion.
The strategy for diagnosis of appendicitis (Fig 1), agreed on by
PEDIATRICS Vol. 113 No. 1 January 2004
29
the 3 pediatric surgeons (who were associated for ⬎20 years), was
as follows: initial pediatric surgical evaluation consisted of his-
tory, physical examination, white blood cell (WBC) count, differ-
ential count, and urinalysis. This was usually done in the emer-
gency department or occasionally on the ward or in the office.
When the diagnosis of appendicitis (without perforation) was
made, the child was prepared for operation. No additional labo-
ratory or radiographic tests were done. Children with perforated
appendicitis received more intensive preparation with intrave-
nous hydration and antibiotics before operation. If a nonsurgical
condition was suspected, eg, streptococcal pharyngitis or pneu-
monia, appropriate diagnostic studies were done, and manage-
ment was continued by the pediatrician or family practitioner. If
the diagnosis remained uncertain, eg, gastroenteritis or early ap-
pendicitis, we preferred that imaging (usually US in girls or CT
scan in boys) be ordered by the pediatric surgeon. The child
received intravenous hydration, nothing by mouth, and was al-
lowed to rest, sometimes with sedation.
A second pediatric surgical evaluation was conducted 4 to 6
hours later consisting of physical examination, usually repeat
WBC count and differential, and radiographic studies as deter-
mined by the pediatric surgeon. If appendicitis was diagnosed, the
child was prepared for appendectomy. If the diagnosis remained
in doubt, the child received hydration and rest for another 4 to 6
hours, after which a third pediatric surgical evaluation was done.
If appendicitis remained a possibility after the third evaluation,
appendectomy was done; otherwise, a nonsurgical diagnosis was
made, and management was conducted in collaboration with the
attending pediatrician or family practitioner.
The medical records of 356 children and adolescents referred
for possible appendicitis from January 1999 through December
2001 were reviewed. Patients were identified from our practice
database by using the diagnoses of appendicitis, perforated ap-
pendicitis, and abdominal pain/possible appendicitis. (Children
with abdominal pain who did not have possible appendicitis were
Fig 1. Algorithm for diagnosis of appendicitis.
30 DIAGNOSIS OF APPENDICITIS BY PEDIATRIC SURGICAL EVALUATION
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not referred and thus were excluded from this patient population.)
Incidental appendectomies performed as part of another proce-
dure were excluded. A standardized data collection tool was used
that included age, gender, duration of symptoms, county of resi-
dence, imaging (US or CT scan), physician ordering imaging stud-
ies, results of imaging studies (positive, negative, or equivocal),
interval (hours) from arrival to pediatric surgical consultation,
interval (hours) from arrival to appendectomy, operative diagno-
sis, and pathologic diagnosis. Pathologic criteria for acute appen-
dicitis were mucosal and intramural inflammation. The presence
of advanced appendicitis, eg, right lower quadrant peritonitis
with or without gross appendiceal perforation was based on the
surgeon’s operative note. The presence of perforation was based
on the pathologist’s report. In children who did not have appen-
dicitis, the discharge diagnosis was recorded. Children who im-
proved under observation were discharged; those who did not
return to the hospital were presumed not to have appendicitis.
Two reviewers (including A.M.K.) performed ⬎95% of chart re-
views, and 2 individuals (including A.M.K.) performed all the
data entry. Outliers were double-checked by a second review of
the original record. The data were entered into a computer pro-
gram (Epi Info 2002, Centers for Disease Control and Prevention,
Atlanta, GA) for analysis. Significance tests were performed to
compare differences between groups. Means were tested by using
the Student t or the Kruskal-Wallace test. ␹2 tests were used for
comparison of categorical variables. Sensitivity, specificity, posi-
tive predictive value, and negative predictive value were calcu-
lated by standard epidemiologic methods.7 Accuracy was calcu-
lated by number of patients with correct diagnoses/total number
of patients. Reports from US or CT which were diagnostically
equivocal were not included in the calculation of accuracy. The
study did not attempt to analyze separate aspects of the pediatric
surgical evaluation (history, physical examination, WBC count,
differential count, or urinalysis) for determination of rank of im-
portance in the diagnostic process.
 RESULTS
The mean age of the 356 patients was 9.6 years
(standard deviation ⫾ 3.83 years; range: 1–18 years).
There were 144 females and 212 males. Of the 356
children, 220 (62%) underwent appendectomy. Of
these 220 children, 209 (95%) had pathologic confir-
mation of appendicitis, and 11 (5%) had a normal
(negative) appendix. Of the 209 children with appen-
dicitis, 139 (66%) had acute appendicitis, 34 (16%)
had advanced appendicitis without perforation, and
36 (17%) had advanced appendicitis with perfora-
tion. There were no significant changes from year to
year across the 3-year period in the proportion of
patients with perforation or with a negative appen-
dix.
Disposition of the patients after initial pediatric
surgical consultation was: operation in 195 (55%) of
the 356 patients; observation in 152 patients (43%);
and discharge home in 9 patients (2%). Of the 152
children who were observed, 25 were subsequently
operated on for appendicitis, and 127 improved un-
der observation (with hydration and supportive ther-
apy) and were discharged from the hospital with a
diagnosis other than appendicitis. One of these 127
children returned to the hospital 6 days later with
perforated appendicitis and was considered a case of
missed appendicitis. The diagnoses of 146 children
who did not have appendicitis are listed in Table 1.
The sensitivity of this protocol for the diagnosis of
appendicitis was 99%, the specificity was 92%, the
positive predictive value was 95%, the negative pre-
dictive value was 99%, and the accuracy was 97%
(Table 2).
Duration of symptoms before arrival at the hospi-
tal was significantly longer for children with ad-
vanced/perforated appendicitis than for those with
early acute appendicitis (mean: 58.2 vs 26.0 hours;
P ⱕ .0001). Median time from arrival at the hospital
to appendectomy in the 195 children diagnosed with
appendicitis at the initial pediatric surgical evalua-
tion was 5 hours. Median time to appendectomy in
the 25 children who had appendectomy after a pe-
riod of observation was 18 hours.
Despite our preference that pediatric surgical eval-
uation be conducted before imaging, 117 imaging
studies (67 US and 50 CT scans) were ordered by the
TABLE 1. Diagnoses of 146 Children and Adolescents Who
Did Not Have Appendicitis
Diagnosis No. of Patients
Gastroenteritis 54
Constipation 31
Abdominal pain 23
Viral syndrome 9
Ovarian cyst 7 1 child (wound infection) of 150 (0.7%) with a non-
Pneumonia 6 perforated appendix. All children survived.
Pharyngitis/strep 4
Mesenteric lymphadenitis 2 DISCUSSION
Pancreatitis 2
Pyelonephritis/urinary tract infection 2
Other* 6 has become routine. Reports advocating the CT scan
Total 146
* 1 each: abdominal wall strain, diabetic ketoacidosis, dysmenor-
rhea, infectious mononucleosis, vomiting (unspecified), and not
recorded.
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referring physician in the 356 children (33%) before
pediatric surgical evaluation. An additional 60 stud-
ies (17%) were ordered by the pediatric surgeon.
(The physician ordering 5 other imaging studies
could not be determined.) US alone was performed
in 96 patients; CT scan alone was performed in 54
patients, and both US and CT scan were performed
in 16 patients. The sensitivity, specificity, positive
predictive value, negative predictive value, and ac-
curacy of the pediatric surgical protocol for US alone
and CT scan alone for diagnosis of appendicitis are
included in Table 2. We did not calculate accuracy of
sequential US and CT scan because only 16 (4.5%) of
356 children had both studies. Fourteen (12.5%) of a
total of 112 US examinations and 8 (11.4%) of a total
of 70 CT examinations were equivocal and omitted
from the calculations. The accuracy of diagnosis was
similar in the children with prereferral diagnostic
imaging studies (102 [94%] of 109) and children who
did not receive such studies (235 [95%] of 247; P ⫽
.5452). Table 3 compares the results of 3 recent re-
ports for diagnosis of appendicitis based on imag-
ing3,8,9 with our series based on clinical evaluation
and selective imaging.
Of the 25 children who had appendectomy after a
period of observation, 8 had acute appendicitis, 6
had advanced appendicitis without perforation, 8
had perforated appendicitis, and 3 had a normal
appendix. The proportion of children with advanced
or perforated appendicitis was greater in the 25 chil-
dren who had appendectomy after observation com-
pared with 195 children who had appendectomy
after initial evaluation (14 [56%] of 25 vs 57 [29%] of
195; P ⫽ .0070). These 25 children, in additional
comparisons with the 195 children with appendec-
tomy after initial evaluation, were similar in age (9.28
vs 10.18 years; P ⫽ .2394) and duration of symptoms
before admission (36.40 vs 36.22 hours; P ⫽ .9795)
but had higher rates of imaging (27 studies [100%] in
25 patients vs 95 [49%] of 195; P ⬍ .0001), incorrect or
equivocal interpretation of imaging (14 [52%] of 27 vs
26 [24%] of 95; P ⫽ .0168), and negative appendec-
tomy (3 [12%] of 25 vs 8 [4%] of 194; P ⫽ .1158).
Nearly 40% (39.6%) of children were referred from
rural counties outside of Lubbock County. Although
mean duration of symptoms was greater in patients
from rural counties than in those from Lubbock
County (46.0 vs 35.1 hours; P ⫽ .0993, using a 1-tailed
test), the rate of advanced/perforated appendicitis
was not different in rural children than in those from
Lubbock County (35.8% vs 29.5%; P ⫽ .3328). Com-
plications (wound infection, intraabdominal abscess,
and prolonged ileus) occurred in 8 (11%) of 70 chil-
dren with advanced/perforated appendicitis and in
In many centers, imaging for possible appendicitis
with rectal contrast as the gold standard for diagno-
sis of appendicitis have appeared in the medical,2,3
pediatric,4 – 6 radiologic,8 emergency medical,10 and
even the surgical11 literature and have had an enor-
ARTICLES 31
 TABLE 2. Epidemiologic Measures of Pediatric Surgical Protocol and of Imaging Techniques for
Diagnosis of Appendicitis in This Series
Basis of No. of Sensitivity Specificity PPV NPV Accuracy
Diagnosis Patients (%) (%) (%) (%) (%)
Pediatric surgical 356 99.5 92.5 95.0 99.3 96.6
protocol
US 112 76.5 88.4 88.6 76.0 81.9
CT scan 70 87.2 80.0 93.2 66.7 90.3
PPV indicates positive predictive value; NPV, negative predictive value.

TABLE 3. A Comparison of Protocols for Diagnosis of Appendicitis

Study Basis of No. of Age* Sensitivity Specificity PPV NPV Accuracy Negative
Diagnosis Patients (y) (%) (%) (%) (%) (%) Appendix
(%)
Rao8 CT scan 100 28 98 98 98 98 98 13
Weyant et al9 CT scan 625 35 96 16 90 NS 88 12
Peña et al3 US ⫹ CT 139 3–21 94 94 90 97 94 12
Present study Clinical ⫹ selective 356 9.6 99 92 95 99 97 5
imaging
PPV indicates positive predictive value; NPV, negative predictive value.
* Mean age of patients (except in the Peña study, in which the mean age was not stated; the range of ages is shown).

mous influence on practice. Few reports have ques-
tioned the accuracy or wisdom of CT scanning for
appendicitis.9,12 Parents of a child with possible ap-
pendicitis may request a CT scan because they have
read about it in the lay press as the definitive test.13
Evaluation by a pediatric surgeon early in the course
of a child with possible appendicitis has rarely been
emphasized.
Our data, however, support a diagnostic strategy
based primarily on the clinical acumen of a pediatric
surgeon rather than imaging. Our sensitivity (99%),
specificity (93%), diagnostic accuracy (97%), and
negative appendectomy rate (5%) compare favorably
with recent reports of imaging-based strategies in
both adults and children (Table 3). Our rate of per-
forated appendicitis (17%) compares favorably to
other large pediatric series since 1995, the rates of
which have ranged from 15.5% to 47%.4,14 –18 Many
different factors are associated with the perforation
rate, which in general varies inversely with age and
directly with duration of illness. Surprisingly, our
large proportion of children (40%) from rural coun-
ties did not have an increased rate of perforation
compared with local children, despite their longer
duration of symptoms.
Because appendicitis is an evolving pathologic
process, and because early appendicitis may be im-
possible to differentiate from other causes of abdom-
inal pain in children, clinical reevaluation after a
period of observation and supportive care may be
necessary. Cost analyses, however, may be biased
toward testing to make the diagnosis at first encoun-
ter; if appendicitis can be ruled out (by testing), the
patient may be sent home from the emergency de-
partment. In an urban setting, this strategy may be
successful, especially if intravenous fluid resuscita-
tion has been completed during the period of testing.
In our rural west Texas population, however, dis-
charge home from the emergency department was
rarely an option.
The 25 children who underwent appendectomy
after a period of observation represented a small
proportion of children who were observed (25 [16%]
of 152) and of children who underwent appendec-
tomy (25 [11%] of 220). Although their rate of ad-
vanced or perforated appendicitis was higher than
that of our 195 children with appendectomy after
first evaluation (56% vs 29%; P ⫽ .0070), it could not
be concluded that the period of observation was
responsible for the higher rate of advanced disease.
Many confounding factors could have influenced the
outcome in these 25 children. For example, the 25
children may have represented a subgroup selected
by greater complexity of their clinical presentations.
This hypothesis is supported by their high rates of
imaging studies, of incorrect or equivocal interpreta-
tion of imaging studies, and of negative appendec-
tomy. Theoretically, the outcome of the observed
patients might have been improved by more timely
surgical decision making and more accurate inter-
pretation of imaging studies. Such refinements might
shorten the period of observation and lower the rate
of advanced/perforated disease.
Because a missed diagnosis often leads to perfora-
tion and complications, rates of negative appendec-
tomy of 12% to 18% are considered acceptable in
children.15,19 A recent nationwide study of ⬎261 000
appendectomies in both adults and children reported
a 15.3% rate of negative appendectomy20 and em-
phasized the potential for enormous cost savings by
a decrease in this rate. Our clinically based approach,
with its low rate of negative appendectomy (5%),
may be more cost-effective than other diagnostic
strategies. We did not perform a cost-effectiveness
analysis in this study because we did not have a
comparison group of children who did not receive
pediatric surgical evaluation early in their manage-
ment for possible appendicitis.
Protocols from tertiary medical centers may not be
generalizable. For example, an imaging protocol for
childhood appendicitis (US followed by CT with rec-
tal contrast) that originated from a large, urban, uni-

32 DIAGNOSIS OF APPENDICITIS BY PEDIATRIC SURGICAL EVALUATION

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versity children’s hospital (Children’s Hospital, Bos-
ton, MA) depended on a coterie of pediatric
radiologists with special interest and expertise in the
radiographic diagnosis of pediatric appendicitis.3– 6
The cost of imaging (US ⫹ CT, in 1997 dollars) was
reported as $907 per patient.6 Other tertiary centers
have chosen opposite strategies with successful out-
comes. One large, urban, university children’s hos-
pital (Children’s Hospital Medical Center, Cincin-
nati, OH), for example, used a clinical, evidence-
based pathway for appendicitis in which pediatric
surgical evaluation was conducted before any tests
were ordered. Imaging was done in doubtful cases.
Quality of care, using as indicators the rates of ap-
pendiceal perforation (25%) and negative appendec-
tomy (12%), was unchanged with this pathway, and
hospital costs were reduced significantly.19 A diag-
nostic strategy that depends on the clinical acumen
of a pediatric surgeon may be more generalizable
than one that requires the technologic skill and ex-
pertise unique to pediatric radiologists.
Improved technology does not always translate
into improved diagnosis and patient outcomes. Wey-
ant et al9 studied 625 patients with appendicitis but
found no correlation between CT findings and
pathologically proven appendiceal disease. A popu-
lation-based study from the state of Washington an-
alyzed 63 707 appendectomies performed during a
12-year period (1987–1998), during which great im-
provements in CT, US, and laparoscopy occurred.
Contrary to expectation, however, the incidence of
negative appendectomies (15.5%) and perforation
(25.8%) did not change with the availability of ad-
vanced diagnostic testing.21
A limitation of our investigation is its retrospective
format. Despite our preference that imaging studies
be ordered by the pediatric surgeon, a CT scan,
which some authors now consider as the definitive
imaging study,4 was ordered in 50 (14%) of 356 chil-
dren by the referring physician before pediatric sur-
gical evaluation. We could not determine retrospec-
tively whether such prereferral imaging was helpful
or superfluous in making the diagnosis of appendi-
citis; however, the data suggest that it may have been
superfluous, because the accuracy of diagnosis of
appendicitis was no better with prereferral imaging
(94%) than without it (95%).
Because the children in our study population were
prescreened by another physician before referral,
they were more likely to have appendicitis than an
unscreened population of children with the initial
presentation of abdominal pain. Selection thus
would account for our relatively high proportion of
children with confirmed appendicitis (62%). Selec-
tion by prescreening, however, does not affect the
study outcomes, ie, the perforation rate or negative
appendectomy rate, because the denominator of
these outcomes is the number of children who actu-
ally undergo operation. Further, selection by pre-
screening does not affect the epidemiologic measures
(sensitivity, specificity, positive predictive value,
negative predictive value, and accuracy), because
these measures are based on correct diagnoses, not
on the proportion of subjects with appendicitis. A
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population that is prescreened to exclude patients
with abdominal pain who have no suspicion of ap-
pendicitis is therefore appropriate and was used by
Peña et al3– 6 in several recent studies on diagnosis of
pediatric appendicitis. Selection bias, which typically
occurs when nonrandomized groups with different
characteristics are compared (incorrectly), is not a
factor if an entire population is selected for an obser-
vational study such as ours and those of Peña et al.
Childhood CT is not innocuous; recent reports in
the radiologic literature have warned of a significant
increase in lifetime radiation risk. Investigators from
Columbia University, alarmed by a rapidly increas-
ing number of pediatric CT examinations, estimated
that 500 individuals currently ⬍15 years old might
ultimately die from cancer attributable to the CT
radiation.22 A study from Belfast documented that
⬃50% of pediatric CT examinations at general hos-
pitals failed to adjust the technique for patient age,
thus exposing children to an unnecessarily high ra-
diation dose.23 Donnelly et al,24 from Cincinnati, out-
lined a strategy for adjustment of standard adult CT
protocols to control the radiation dose in children.
The risk is not theoretical but is based on Japanese
data on actual excess cancer in those who were irra-
diated as children in 1945.25 Because children are 10
times more sensitive than adults to the induction of
cancer, Hall26 estimated that an abdominal helical CT
scan in a young girl results in a risk of fatal cancer
later in life that amounts to about 1 in 1000. The
public health problem becomes significant when the
small individual risk is multiplied by the 2.7 million
of such procedures performed annually.26 Thus a
strategy that relies on careful history and physical
examination and minimizes radiation exposure may
be inherently safer than one that relies on routine
imaging. Future investigations should consider the
risk of radiation exposure against possible benefits in
cost effectiveness or diagnostic accuracy for this
common pediatric condition.
ACKNOWLEDGMENTS
We are grateful to Christy Ratheal, RN, for keeping our practice
database and for assistance with data entry; Catherine Lovett, RN,
BS, for assistance with data collection; and John Griswold, MD, for
encouragement and expert advice.
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GOING AFTER THE UNINSURED

“The charges issues has become a focus of healthcare advocates, who have
flagged a major inequity in the billing system: While hospitals negotiate discounts
with insurers and HMOs that require payment of only a fraction of the listed
charges, they ask the uninsured to pay the full rates and then pursue them
aggressively to collect.”

Lagnado L. Hospitals urged to end harsh tactics for billing uninsured. Wall Street Journal, July 7, 2003

Submitted by Student

34 DIAGNOSIS OF APPENDICITIS BY PEDIATRIC SURGICAL EVALUATION

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 The Diagnosis of Appendicitis in Children: Outcomes of a Strategy Based on
Pediatric Surgical Evaluation
Ann M. Kosloske, C. Lance Love, James E. Rohrer, Jane F. Goldthorn and Stuart R.
Lacey
Pediatrics 2004;113;29
DOI: 10.1542/peds.113.1.29

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 The Diagnosis of Appendicitis in Children: Outcomes of a Strategy Based on
Pediatric Surgical Evaluation
Ann M. Kosloske, C. Lance Love, James E. Rohrer, Jane F. Goldthorn and Stuart R.
Lacey
Pediatrics 2004;113;29
DOI: 10.1542/peds.113.1.29

The online version of this article, along with updated information and services, is
located on the World Wide Web at:
http://pediatrics.aappublications.org/content/113/1/29

Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it
has been published continuously since 1948. Pediatrics is owned, published, and trademarked by
the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois,
60007. Copyright © 2004 by the American Academy of Pediatrics. All rights reserved. Print ISSN:
1073-0397.

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