Hypothesis Clinical use of a diagnostic score improves decision making in acute appendicitis.
Design A before-and-after trial comparing a group of patients undergoing standard diagnostic workup with no additional diagnostic support (phase 1) with a group of patients undergoing additional diagnostic support with a score (phase 2).
Setting Eight departments of surgery in Germany and Austria.
Patients Eight hundred seventy patients with acute abdominal pain in phase 1 (October 1, 1994, to April 30, 1995) and 614 patients in phase 2 (February 1, 1995, to August 15, 1995).
Interventions Structured and standardized history and clinical investigation in all patients with computer-based documentation; introduction of the diagnostic score after phase 1 and computer-supported use of the score in phase 2.
Results The 2 groups were comparable with respect to signs, symptoms, and investigations related to acute appendicitis. Diagnostic performance of the final examiner decreased with the score (specificity, 86% vs 78%; positive predictive value, 67% vs 50%; and accuracy, 88% vs 81%). There were no differences in the rates of perforated appendix, appendectomy with normal findings, and complications; however, the delayed appendectomy rate (2% vs 8%) and the delayed discharge rate (11% vs 22%) were significantly lower with diagnostic support by the score (P=.02).
Conclusions Integration of a score into the diagnostic process may have unforeseen clinical effects. The tested score cannot be recommended as a standard tool for diagnostic decision making in acute appendicitis.
