Optimizing management of children presenting with acute abdominal pain in primary care: a cluster randomized controlled trial evaluating the impact of a clinical prediction rule including C-reactive protein for appendicitis

Gea Holtman, Guus Blok, Michiel De Boer, Marjolein Berger, Huib Burger

Keywords: cluster RCT, appendicitis, children, diagnostic strategy

Background:

It is difficult for the general practitioner (GP) to distinguish harmless acute abdominal pain from acute appendicitis (AA) at an early stage. This results in missing 19% of children with AA at first presentation in primary care and 70% non-AA cases among referrals which has a negative impact on the child and parents.

Research questions:

What is the impact of using a clinical prediction rule (cPR) including C-reactive protein point-of-care test (CRP POCT) for AA on referral efficiency and safety in children with acute abdominal pain in primary care, as compared with usual care?

Method:

This will be a cluster randomized controlled trial in primary care. Children aged 4 to 18 years presenting to their GP with acute abdominal pain will be included. The intervention is a diagnostic strategy for AA referral using an externally validated cPR based on symptoms and signs selectively followed by a CRP POCT in the medium risk group. GPs in the control group will perform usual care according to the Dutch College of GPs guideline ‘abdominal pain in children‘, which does not include specific recommendations for AA referral and CRP POCT test is not recommended. The co-primary outcomes are efficiency (proportion non-referrals in non-AA patients during 30 days follow-up) and safety (proportion referrals in AA patients during first consultation).

Results:

In 2024 we will start developing and testing the e-learning and decision-making tool for GPs. Thereafter, we will start recruiting and training GPs and include patients. We aim to include 566 children, from 150 GP practices, to determine an improvement in efficiency of 88% to 95% and non-inferiority of safety (81%).

Conclusions:

We expect that this diagnostic strategy could be a child-friendly and cost-effective solution to reduce the number of non-AA referrals without increasing the number of missed AA children at first presentation.

Points for discussion:

How can we deal with the preferences of parents to be referred to the hospital?

How can we increase the awareness among GPs for the diagnostic strategy?

How should we design the e-learning to educate GP’s such that they will implement the diagnostic strategy in daily practice?

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