PROJECT SUMMARY ABSTRACT: Candidate: Dr. Courtney Mangus is a pediatric emergency medicine (EM) physician and health services researcher at the University of Michigan (U-M) Medical School. She is interested in identifying and testing ways to improve diagnostic safety and patient engagement via shared decision-making (SDM) in the community emergency department (ED) setting, which is under-resourced compared to tertiary care EDs. Her goal is to become an independent investigator and leader in the field, improving the quality of care for children evaluated for common pediatric conditions, such as abdominal pain, in community EDs. Research Context: The most common pediatric surgical emergency, appendicitis, is ideally diagnosed with ultrasonography. However, 85% of children seek care in community EDs, which often have limited resources. As such, children presenting with abdominal pain in this setting are more likely to undergo computed tomography (CT). CT imaging is the most sensitive diagnostic test for appendicitis, but it exposes children to ionizing radiation and ultimately increases their risk of developing cancer. Risk stratification tools exist to help clinicians determine which children with abdominal pain require imaging, but for the ~50% children in community EDs who fall into the group of intermediate risk for appendicitis, clinicians often face a dilemma regarding next diagnostic steps. Data suggest most clinicians choose either 1) CT imaging or 2) watchful waiting (observation or discharge with scheduled follow-up). Because this dilemma is so common, a systematic, family-centered approach is needed to communicate diagnostic options, including risks/benefits, and engage families in the decision-making process. Development and implementation of an intervention to facilitate SDM in this scenario has the potential to reduce unnecessary CT scans and increase family engagement in the diagnostic process. Research Aims: In this project, Dr. Mangus will utilize an iterative, user-centered design approach to develop and refine a risk- tailored intervention to facilitate SDM in the diagnosis of pediatric abdominal pain in the community ED setting (Aims 1a/1b) and pilot the intervention via a randomized controlled trial of 100 ED patients presenting with signs and symptoms of appendicitis to a community ED (Aim 2). The research will be conducted at Hurley Medical Center (HMC), a community hospital in Flint, Michigan, which serves a large population of racial/ethnic minority and low-income children (AHRQ priority populations). Career Development Plan: Dr. Mangus will undertake the proposed research plan under the expert mentorship of Drs. Mahajan, Manojlovich, Schoenfeld and Singh. Her career development curriculum is focused on mixed methods research, training in SDM intervention development, and clinical trial methodology. The proposal utilizes the resources of the U-M Department of EM, U-M’s Center for Bioethics and Social Sciences in Medicine, the U-M Institute for Healthcare Policy and Innovation, and HMC. In alignment with the mission of AHRQ, Dr. Mangus’ long-term goals are to improve patient-centered care and diagnostic safety for children requiring emergency care.

PROJECT NARRATIVE: In well-resourced, tertiary care emergency departments (EDs), ultrasonography or magnetic resonance imaging are typically used to diagnose appendicitis, the most common pediatric surgical emergency, in children presenting to the ED with abdominal pain. Clinicians in resource-limited settings such as community EDs, however, encounter a diagnostic dilemma in these situations: they must often choose between computed tomography (CT), which carries the risk of radiation exposure, and watchful waiting, which carries the risk of delayed diagnosis. We aim to develop and test a shared decision-making intervention that would allow ED clinicians and patients/families to make the decision about diagnostic next steps together, with the goal of optimizing resource utilization, increasing patient/family engagement, and reducing unnecessary CT scans without increasing the risk of delayed diagnosis of acute appendicitis.