Abstract
BackgroundThe Alvarado score can be used to stratify patients with symptoms of suspected appendicitis; the validity of the score in certain patient groups and at different cut points is still unclear. The aim of this study was to assess the discrimination (diagnostic accuracy) and calibration performance of the Alvarado score.MethodsA systematic search of validation studies in Medline, Embase, DARE and The Cochrane library was performed up to April 2011. We assessed the diagnostic accuracy of the score at the two cut-off points: score of 5 (1 to 4 vs. 5 to 10) and score of 7 (1 to 6 vs. 7 to 10). Calibration was analysed across low (1 to 4), intermediate (5 to 6) and high (7 to 10) risk strata. The analysis focused on three sub-groups: men, women and children.ResultsForty-two studies were included in the review. In terms of diagnostic accuracy, the cut-point of 5 was good at 'ruling out' admission for appendicitis (sensitivity 99% overall, 96% men, 99% woman, 99% children). At the cut-point of 7, recommended for 'ruling in' appendicitis and progression to surgery, the score performed poorly in each subgroup (specificity overall 81%, men 57%, woman 73%, children 76%). The Alvarado score is well calibrated in men across all risk strata (low RR 1.06, 95% CI 0.87 to 1.28; intermediate 1.09, 0.86 to 1.37 and high 1.02, 0.97 to 1.08). The score over-predicts the probability of appendicitis in children in the intermediate and high risk groups and in women across all risk strata.ConclusionsThe Alvarado score is a useful diagnostic 'rule out' score at a cut point of 5 for all patient groups. The score is well calibrated in men, inconsistent in children and over-predicts the probability of appendicitis in women across all strata of risk.
Highlights
The Alvarado score can be used to stratify patients with symptoms of suspected appendicitis; the validity of the score in certain patient groups and at different cut points is still unclear
Clinical prediction rules (CPRs) quantify the diagnosis of a target disorder based on findings of key symptoms, signs and available diagnostic tests, having an
Further investigations, such as ultrasound and computed tomography (CT) scanning, are recommended when probability of appendicitis is in the intermediate range
Summary
The Alvarado score can be used to stratify patients with symptoms of suspected appendicitis; the validity of the score in certain patient groups and at different cut points is still unclear. Symptoms of appendicitis overlap with a number of other conditions making diagnosis a challenge, at an early stage of presentation [2]. Patients may be suitably triaged into alternative management strategies: reassurance, pursuit of an alternative diagnosis or observation/admission to hospital. The Alvarado score enables risk stratification in patients presenting with abdominal pain, linking the probability of appendicitis to recommendations regarding discharge, observation or surgical intervention [5]. Further investigations, such as ultrasound and computed tomography (CT) scanning, are recommended when probability of appendicitis is in the intermediate range
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