Authors: Golden SK et al., Emerg Med J 2016 Jul 33:458
Neither clinical scoring systems nor physician gestalt, alone or in combination, adequately risk stratified patients with appendicitis.
Several scoring systems have been developed to risk stratify patients with suspected appendicitis. To determine how they compare with physician’s estimates of risk, researchers conducted a prospective observational study of 287 patients older than 11 years (mean age, 31) undergoing computed tomography (CT) for suspected appendicitis at a single academic medical center during a 2-year period.
The prevalence of CT-confirmed appendicitis was 33%. The positive likelihood ratios for accurately predicting the case incidence of appendicitis were as follows:
- Physician-determined alone: 1.3
- Alvarado score: 2.2 alone; 3.7 combined with gestalt
- Modified Alvarado score: 2.4 alone; 3.9 combinedRaja Isteri Pengiran Anak Saleha Appendicitis (RIPASA) score: 1.3 alone; 2.3 combined
- Negative likelihood ratios ranged from 0.3 for physician gestalt alone to 0.7 for modified Alvorado score alone. The authors conclude that neither physician gestalt nor any of the scoring tools, alone or in combination, has the diagnostic accuracy to predict the incidence of appendicitis.
Decreasing avoidable radiation exposure has become a focus of quality-measure developers, clinicians, patients, and the lay press. This overly complicated study adds to the mounting evidence that current decision-support tools for risk stratifying patients with appendicitis are inadequate. For now, we need to continue to use good old-fashioned clinical judgement and knowledge of the evidence to guide our decision making.