Nationwide prospective audit for the evaluation of appendicitis risk prediction models in adults: right iliac fossa treatment (RIFT)—Turkey
Authors: Yalcinkaya Ali , Yalcinkaya Ahmet , Balci Bengi , Keskin Can , Erkan Ibrahim , Yildiz Alp , Kamer Erdinc , Leventoglu Sezai ,   RIFT TURKEY Study Collaboration, Yalcinkaya Ali , Yalcinkaya Ahmet , Keskin Can , Erkan Ibrahim , Leventoglu Sezai , Caglikulekci Mehmet , Zarbaliyev Elbrus , Sevmis Murat , Ulgen Yigit , Altinel Yuksel , Meric Serhat , Akbas Ahmet , Hacim Nadir Adnan , Vartanoglu Aktokmanyan Talar , Aktimur Yunus Emre , Calikoglu Fikret , Gullu Hasim Furkan , Durma Ahmet Guray , Acar Sami , Ciftci Erman , Balik Emre , Kulle Cemil Burak , Ozata Ibrahim Halil , Tufekci Tutku , Tatar Cihad , Sevinc Mert Mahsuni , Sevik Husnu , Ertürk Candeniz , Kiraz Irem Nur , Ozben Volkan , Aytac Erman , Aliyeva Zumrud , Mutlu Arda Ulas , Tanal Mert , Celayir Mustafa Fevzi , Bozkurt Emre , Yetkin Sitki Gurkan , Ergin Emin , Attaallah Wafi , Uprak Tevfik Kivilcim , Omak Ahmet , Simsek Oguzhan , Bozkurt Mehmet Abdussamet , Kara Yasin , Bozdag Emre , Yirgin Hakan , Ozcan Adem , Okkabaz Nuri , Ozdenkaya Yasar , Haksal Mustafa Celalettin , Pekuz Caglar Kazim , Duru Sila , Sivrikoz Emre , Ozdemir Yavuz , Tan Necati , Yarbug Karayali Feza , Taghiyeva Abdulla , Tirnova Ismail , Erenler Bayraktar Ilknur , Bayraktar Onur , Emsal Emine Zulal , Dalkilic Munevver Irem , Yesiltas Metin , Tok Hasan , Karakas Dursun Ozgur , Pusane Ali , Demirer Ali Ilbey , Sahin Hasan Berk , Gok Ali Fuat Kaan , Bozkurt Halil Alper , Yildirim Mehmet Iskender , Uzunyolcu Gorkem , Yanar Hakan Teoman , Ergun Sefa , Kutluk Fadime , Uludag Server Sezgin , Zengin Abdullah Kagan , Ozcelik Mehmet Faik , Sanli Ahmet Necati , Altuntas Yunus Emre , Memisoglu Ecem , Sari Ramazan , Akdogan Osman , Kucuk Hasan Fehmi , Ozkan Omer Faruk , Ulgur Hanife Seyda , Kirkan Emre Furkan , Yuksekdag Sema , Rencuzogullari Ahmet , Aktas Melik Kagan , Aba Murat , Demirel Ahmet Onur , Eray Ismail Cem , Aydogan Burak , Cetinkunar Suleyman , Yener Kemal , Sozutek Alper , Irkorucu Oktay , Bayrak Mehmet , Altintas Yasemin , Alabaz Omer , Atasever Ahmet , Erdogrul Guven , Kupeli Aydın Hakan , Muhammedoglu Bahtiyar , Kokdas Suleyman , Kaya Murat , Uysal Erkan , Yildirim Ali Cihat , Zeren Sezgin , Ekici Mehmet Fatih , Algin Mustafa Cem , Kucuk Gultekin Ozan , Eraslan Huseyin , Aybar Engin , Polat Suleyman , Ceylan Alper , Isik Ozgen , Kural Said , Aktas Ahmet , Bakar Burak , Uzunoglu Mustafa Yener , Gulcu Baris , Ozturk Ersin , Devay Ali Onder , Taspinar Ersoy , Balcin Ozkan , Aksoy Fuat , Garip Gokhan , Yalkin Omer , Iflazoglu Nidal , Yigit Direnc , Kaya Rumeysa Betul , Ugur Mustafa , Kilic Erol , Dedemoglu Akin , Arslan Rasim Ersin , Temiz Muhyittin , Aydin Cengiz , Demirli Atici Semra , Kaya Tayfun , Ozturk Selen , Calik Bulent , Kilinc Gizem , Kamer Erdinc , Acar Turan , Acar Nihan , Cengiz Fevzi , Ureyen Orhan , Tan Sedat , Yildirim Mehmet , Ilhan Enver , Turk Yigit , Durak Ahmet Turan , Yilmaz Mehmet , Mercan Metin , Atci Recep , Sokmen Selman , Bisgin Tayfun , Egeli Tufan , Yildirim Yasemin , Safak Turugsan , Celik Kazim , Yilmaz Eyup Murat , Kirnap Mahir , Demirkiran Ahmet Ender , Sekerci Ulas Utku , Karacan Erkan , Bilgic Ethem , Ozmen Mehmet Mahir , Guldogan Cem Emir , Gundogdu Emre , Moran Munevver , Erol Timucin , Dincer Hilmi Anil , Kirimtay Busenur , Yilmaz Sumeyye , Cennet Omer , Yildiz Alp , Yildiz Aybala , Sahin Can , Akyol Cihangir , Koc Mehmet Ali , Ersoz Siyar , Turhan Anil , Konca Can , Tezcaner Tugan , Erkent Murathan , Aydin Onur , Avci Tevfik , Altiner Saygin , Osmanov Igbal , Emral Ahmet Cihangir , Cetinkaya Gokay , Lapsekili Emin , Sakca Merve , Cimen Sebnem , Ozen Dogan , Kozan Erdem Baran , Dogan Lutfi , Haberal Elifcan , Balci Bengi , Kayhan Okan , Aksel Bulent , Karabacak Harun , Azili Cem , Yazici Faruk , Apaydin Muhammed , Kaya Ismail Oskay , Cetinkaya Erdinc , Akin Tezcan , Gunes Gizem , Turap Huseyin , Aslan Deniz , Demirbag Ali Eba , Bolukbasi Basak , Karaca Berkay Enes , Ozturk Ece , Ozeller Elif , Kayacan Gulsum Sueda , Borcek Alp Ozgun , Ece Ilhan , Yormaz Serdar , Colak Bayram , Calisir Akin , Sahin Mustafa , Arslan Kemal , Hasirci Ismail , Ulutas Mehmet Esref , Metin Sukru Hakan , Gultekin Fatma Ayca , Ozkan Zeynep , Ilhan Onur , Gundogdu Tamer , Liman Rumeysa Kevser , Kanat Burhan Hakan , Aydin Altan , Sungurtekin Ugur , Ozgen Utku , Aykota Muhammed Rasid , Altintoprak Fatih , Gonullu Emre , Cakmak Guner , Dulger Ugur Can , Mantoglu Baris , Demir Hakan , Akin Emrah , Eroz Erhan , Nazli Okay , Dere Ozcan , Dadasoglu Mustafa Aykut , Kara Eray , Tutcu Semra , Solak Ilhami , Gencer Ilayda , Dalkiran Alperen , Sevinc Baris , Karahan Omer , Damburaci Nurullah , Sari Erdem , Akay Tamer , Calta Alpaslan Fedayi , Ozdemir Abdullah , Ohri Nurian , Ermis Ilker , Bozbiyik Osman , Ozdemir Murat , Goktepe Berk , Demir Batuhan , Kilincarslan Ozgur , Gunduz Umut Riza , Olcum Mehmet , Dincer Onur Ilkay , Cakir Remzi Can , Dinc Bulent , Sahin Enes , Uludag Emrah , Arslan Yusuf , Posteki Gokhan , Oktay Ahmet , Tatar Ozan Can , Guler Sertac Ata , Utkan Nihat Zafer , Tayar Serkan , Copelci Yasar , Kartal Murat , Kalayci Tolga , Yeni Mustafa , Buyukkasap Ahmet Cagri , Vural Selahattin , Kesicioglu Tugrul , Aydin Ismail , Gulmez Mehmet , Saracoglu Can , Topcu Omer , Kurt Atilla , Soylu Sinan , Kurt Begum , Serin Musa , Basceken Salim Ilksen , Gundes Ebubekir , Savda Mervan , Balkan Ali Zeynel Abidin , Yildiz Mehmet Nuri , Uzunkoy Ali , Karaca Emre , Berkan Ahmet , Isik Arda , Yildiz Yasin Alper , Ergul Zafer , Yasar Necdet Fatih , Badak Bartu , Ozen Ata , Velipasaoglu Melih , Ure Iyimser 
Published: October 2024

Abstract

Background
Appendicitis is the most prevalent surgical emergency. The negative appendicectomy rate and diagnostic uncertainty are important concerns. This study aimed to assess the effectiveness of current appendicitis risk prediction models in patients with acute right iliac fossa pain.

Methods
A nationwide prospective observational study was conducted, including all consecutive adult patients who presented with right iliac fossa pain. Diagnostic, clinical and negative appendicectomy rate data were recorded. The Alvarado score, Appendicitis Inflammatory Response (AIR), Raja Isteri Pengiran Anak Saleha Appendicitis (RIPASA) and Adult Appendicitis Score systems were calculated with collected data to classify patients into risk categories. Diagnostic value and categorization performance were evaluated, with use of risk category-based metrics including ‘true positive rate’ (percentage of appendicitis patients in the highest risk category), ‘failure rate’ (percentage of patients with appendicitis in the lowest risk category) and ‘categorization resolution’ (true positive rate/failure rate).

Results
A total of 3358 patients from 84 centres were included. Female patients were less likely to undergo surgery than men (71.5% versus 82.5% respectively; relative risk 0.866, 95% c.i. 0.834 to 0.901, P &lt; 0.001); with a three-fold higher negative appendicectomy rate (11.3% versus 4.1% respectively; relative risk 2.744, 95% c.i. 2.047 to 3.677, P &lt; 0.001). Ultrasonography was utilized in 56.8% and computed tomography in 75.2% of all patients. The Adult Appendicitis Score had the best diagnostic performance for the whole population; however, only RIPASA was significant in men. All scoring systems were successful in females patients, but Adult Appendicitis Score had the highest area under the receiver operating characteristic curve value. The RIPASA and the Adult Appendicitis Score had the best categorization resolution values, complemented by their exceedingly low failure rates in both male and female patients. Alvarado and AIR had extremely high failure rates in men.

Conclusion
The negative appendicectomy rate was low overall, but women had an almost three-fold higher negative appendicectomy rate despite lower likelihood to undergo surgery. The overuse of imaging tests, best exemplified by the 75.2% frequency of patients undergoing computed tomography, may lead to increased costs. Risk-scoring systems such as RIPASA and Adult Appendicitis Score appear to be superior to Alvarado and AIR.