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Structured Management of Patients with Suspected Acute Appendicitis Using a Clinical Score and Selective Imaging (STRAPPSCORE)
Linköping University, Department of Clinical and Experimental Medicine, Division of Clinical Sciences. Linköping University, Faculty of Health Sciences. County Hospital Ryhov, Jönköping, Sweden .
Department of Pathology, Ryhov County Hospital, County Council of Jönköping, Jönköping, Sweden.
Linköping University, Department of Clinical and Experimental Medicine, Division of Clinical Sciences. Linköping University, Faculty of Health Sciences. County Hospital Ryhov, Jönköping, Sweden.
2015 (English)Manuscript (preprint) (Other academic)
Abstract [en]

Background

The management of patients with suspected appendicitis is highly variable with implications for the rate of diagnostic errors, unnecessary admissions and resource consumption. We hypothesise that a structured management algorithm based on the Appendicitis Inflammatory Response (AIR) score can improve diagnostic accuracy, limit the use of diagnostic imaging, and reduce the number of hospital admissions for patients with suspected appendicitis.

Methods

Prospective interventional multicentre study. Patients at 25 Swedish hospitals over the age of five, presenting with suspected appendicitis at the emergency department were considered for inclusion. After an initial period of routine management and registration of the AIR score parameters (baseline period), an AIR-score-based management algorithm was implemented (intervention period). The study analyses the discriminating capacity and predictive value of the AIR score and the impact of implementing the AIR-score-based algorithm.

Results

In total, 3791 patients were included. Advanced appendicitis is unlikely at an AIR score <5 points (sensitivity 0.96), and appendicitis is likely at an AIR score >8 (specificity 0.98). The implementation of the AIR-score-based algorithm resulted in fewer negative explorations and operations for phlegmonous appendicitis (1.6% vs 3.4%, p=0.019 and 5.5% vs 9.4%, p=0.003, respectively), a reduction in admissions to hospital and use of imaging (29.5% vs 42.8%, p<0.001 and 19.2% vs 34.5%, respectively), and no difference with regard to advanced appendicitis in the low-risk group, and a decrease in the use of diagnostic imaging in the high-risk group (38.5% vs 53.1%, p=0.021).

Conclusions

The AIR score has high discriminating capacity. Implementing an AIR-score-based algorithm increased diagnostic accuracy and lowered the use of diagnostic imaging and in-hospital observation.

Place, publisher, year, edition, pages
2015.
National Category
Clinical Medicine
Identifiers
URN: urn:nbn:se:liu:diva-113764OAI: oai:DiVA.org:liu-113764DiVA: diva2:784630
Funder
Futurum - Academy for Health and Care, Jönköping County Council, SwedenMedical Research Council of Southeast Sweden (FORSS)
Available from: 2015-01-30 Created: 2015-01-30 Last updated: 2015-01-30Bibliographically approved
In thesis
1. Structured management of patients with suspected acute appendicitis
Open this publication in new window or tab >>Structured management of patients with suspected acute appendicitis
2015 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Background. Acute appendicitis (“appendicitis”) is one of the most common abdominal surgical emergencies worldwide. In spite of this, the diagnostic pathways are highly variable across countries, between centres and physicians. This has implications for the use of resources, exposure of patients to ionising radiation and patient outcome. The aim of this thesis is to construct and validate a diagnostic appendicitis score, to evaluate new inflammatory markers for inclusion in the score, and explore the effect of implementing a structured management algorithm for patients with suspected appendicitis. Also, we compare the outcome of management with routine diagnostic imaging versus observation and selective imaging in equivocal cases.

Methods. In study I, the Appendicitis Inflammatory Response (AIR) score was constructed from eight variables with independent diagnostic value (right lower quadrant pain, rebound tenderness or muscular defence, WBC count, proportion of polymorphonuclear granulocytes, CRP, body temperature and vomiting). Its diagnostic properties were evaluated and compared with the Alvarado score. In study II, we performed an external validation and evaluation of novel inflammatory markers for inclusion in the score on patients with suspected appendicitis at two Swedish hospitals. In study III we externally validated and evaluated the impact of an AIR-scorebased algorithm assigning patients to a low or high risk of having appendicitis in an interventional multicentre study involving 25 Swedish hospitals and 3791 patients. In study IV, we compared the efficiency of routine diagnostic imaging with repeated clinical assessment followed by selective imaging in a randomised trial of 1028 patients with equivocal signs of appendicitis, as indicated by an intermediate AIR score, from study III.

Main results. In study I we found that the AIR score could assign 63% of the patients to either a high- or low-risk group of appendicitis with an accuracy of 97%, which compared favourably with the Alvarado score. In study II, the diagnostic properties of the AIR score proved to be  reproducible, but the inclusion of novel inflammatory markers did not improve the diagnostic accuracy. In study III, the AIR-score-based algorithm led to a reduction in negative explorations, operations for nonperforated appendicitis and hospital admissions in the low-risk group and reduced use of imaging in both low- and high-risk groups. In study IV, routine imaging led to more operations for nonperforated appendicitis but had no effect on negative explorations or perforated appendicitis.

Conclusions. The AIR score was found to have promising diagnostic properties that were not improved further with the inclusion of novel inflammatory variables. Structured management of patients with suspected appendicitis according to an AIR-score-based algorithm may improve outcome while reducing hospital admissions and use of imaging. Patients with equivocal signs of appendicitis do not benefit from routine imaging which may lead to an increased detection of, and treatment for, uncomplicated cases of appendicitis that are otherwise allowed to resolve spontaneously.

Place, publisher, year, edition, pages
Linköping: Linköping University Electronic Press, 2015. 110 p.
Series
Linköping University Medical Dissertations, ISSN 0345-0082 ; 1442
National Category
Clinical Medicine Surgery
Identifiers
urn:nbn:se:liu:diva-113766 (URN)10.3384/diss.diva-113766 (DOI)978-91-7519-137-9 (ISBN)
Public defence
2015-03-06, Originalet, Qulturum, Länssjukhuset Ryhov, Jönköping, 13:00
Opponent
Supervisors
Funder
Futurum - Academy for Health and Care, Jönköping County Council, SwedenMedical Research Council of Southeast Sweden (FORSS)
Available from: 2015-01-30 Created: 2015-01-30 Last updated: 2015-11-16Bibliographically approved

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