Randomized Control Trial Comparing Proposed Algorithm and Current Best Practice in the Evaluation of Suspected Appendicitis

Acute appendicitis is one of the most common causes of acute abdominal pain requiring surgical intervention, with a lifetime risk of 8.6% for males and 6.7% for females. Historically, negative appendectomy rates of more than 20% were considered the norm. This is no longer acceptable in the current era, as despite low complication rates in the setting of negative appendectomy, conditions such as incisional hernias, intestinal obstruction secondary to adhesions and stump leakages can still result in significant morbidity.

Computed Tomography (CT) scan has emerged as the dominant imaging modality for evaluation of suspected appendicitis in adults. It has decreased negative appendectomy rates to fewer than 10%. However, the radiation exposure with CT poses a concern, particularly in appendicitis, which occurs predominantly in young patients most susceptible to the adverse effects of radiation. Available literature has estimated that at least 25% of CT scans are not clinically warranted and may pose more harm than benefits. Rules for clinical decision guiding CT utilization is thus essential to minimize unnecessary CT scans, which not only poses a radiation risk but also contributes to increased healthcare costs.

Currently, the management of suspected appendicitis is surgeon dependent. Accuracy of diagnosis is dependent on individual's clinical acumen, preference for CT scan and threshold for offering surgery. There is also a recent trend towards indiscriminate CT utilization with an estimated 1 in 4 CT scans ordered found to be clinically unwarranted. The Alvarado Score (AS) is a 10 point clinical scoring system for acute appendicitis that has been extensively validated. AS on a prospective database of 500 consecutive cases of suspected appendicitis admitted to Singapore General Hospital, Department of General Surgery from August 2013 to July 2014, was validated. A comparison was then made between diagnostic performance measures of CT scan and AS to identify ranges of AS where patients are unlikely to benefit from CT evaluation. From these findings, an objective algorithm for the management of suspected appendicitis guided by AS was formulated. Ideally, the algorithm will streamline CT utilization and reduce the number of CT scans ordered with an acceptable negative appendectomy rate. Thus, investigators hope to validate this proposed algorithm through a randomized control trial.

The trial will recruit 160 eligible patients over 2 years. Eligible patients who consented to participate in the trial will be subjected to randomization into one of the two trial groups - Usual Care Arm or Intervention Arm - in equal numbers (n=80). Patients randomized to Usual Care Arm will be managed according to individual's doctor discretion. On the other hand, patients randomized to Intervention Arm will have their Alvarado Score tabulated and managed as per proposed algorithm.

The primary objective of the trial is to show that the proposed management algorithm is effective in reducing the percentage of CT utilization as compared to current best practice for patients with suspected appendicitis seen at Singapore General Hospital and Sengkang Health. The hypothesis is that the proposed management algorithm will reduce the percentage of CT scans from 80%, which is the CT utilization rate when current best practice is used, to 60%. The study will be powered to detect this decrease with a 5% type I error rate.