O knowledge, where art thou? Evidence and suspected appendicitis

Much effort goes into developing and publishing guidelines which physicians fail to implement. We feel that major discrepancies still exist between theory and reality and that the translational approach to this aspect of medical care has not yet established itself. We therefore decided to investigate in an exemplary audit how liberally inappropriate imaging is used in our emergency department (ED) to rule out acute appendicitis.

Our electronic medical record ED database 'Qualicare' (http://www.qualidoc.ch) was searched using the 'appendicitis' sub data base. The frequency and accuracy of abdominal imaging was determined in patients with clinically suspected appendicitis on admission over a 5-year period at a university hospital emergency unit.

In total, 272 (41.2%) of the 577 patients were male and 305 (46.3%) were female. The attending physicians ordered abdominal X-rays in 133 patients, abdominal ultrasounds in 319, and abdominal computerized tomography (CT) scans in 93 patients. 125 patients underwent more than one imaging procedure. In all, 85/125 patients received a combination of X-rays, ultrasound and CT scanning!

Physicians are often insecure about indications for surgery and therefore order useless imaging procedures. The reliability of such procedures in excluding acute appendicitis is limited, which was confirmed by our results. Although evidence-based medicine guidelines exist, they are neglected for many reasons. Future academic efforts should therefore focus more on knowledge translation and the implementation of existing knowledge by heightening awareness, rather than on simply creating new guidelines.