The Alvarado Score for appendicitis has been around a long time – 1986, to be precise. Initially proposed to help with the diagnosis of appendicitis prior to advanced imaging, in a different surgical and observation culture, it has effectively been replaced in cost-effectiveness and timeliness by CT. These authors, however, want to resurrect it in the face of increasing CT overuse.
These authors perform a simple retrospective review of CTs performed at their single institution evaluating patients for abdominal pain, and then retrospectively calculated Alvarado scores from medical record review. Methods are incompletely described, but, effectively, they found about 20% of their 492 cases were Alvarado score ≥9 – and all had appendicitis – or Alvarado score ≤2 – and nearly all were absent appendicitis – and suggest any patients with scores at those extremes should not receive imaging, thus reducing ED length-of-stay and radiation exposure.
It should probably say something that a clinical tool has been around over 30 years without truly gaining traction. I don’t think their proposal is unreasonable – whether using Alvarado or gestalt – to consult prior to imaging for cases with high clinical likelihood, or to discharge with return instructions for cases that are inconsistent with the diagnosis. Cultural factors need to change on both ends of the spectrum, however, to support imaging reduction practice change. Finally, despite the commanding nature of their article title, this is hardly the level of evidence or statistical power to truly describe the safety or effectiveness of this strategy – there are more patients here than in many prospective studies, but this does not replace a well-designed trial, or even some sort of pre-/post-intervention report.
Also: “This study was presented at the 75th meeting of the American Association for the Surgery of Trauma, September 14-17th, 2016 in Waikoloa, Hawaii.” Ah, nice.
“The Alvarado Score Should Be Used To Reduce Emergency Department Length of Stay and Radiation Exposure in Select Patients with Abdominal Pain”