Wen S W, Naylor C D
Institute for Clinical Evaluative Sciences in Ontario.
CMAJ. 1995 May 15;152(10):1617-26.
To test the hypothesis that, with modern diagnostic methods and antibiotics, more conservative use of surgery in cases of suspected appendicitis would not result in increased rates of short-term complications in confirmed cases.
Population-based observational study using administrative data.
All Ontario hospitals in which primary appendectomy was performed from Apr. 1, 1981, to Mar. 31, 1992.
All 126,815 patients admitted to hospital for a primary appendectomy during the study period.
Diagnostic accuracy rate (acute appendicitis as the primary diagnosis), perforation rate, in-hospital death rate and length of stay.
The diagnostic accuracy rate among the male patients was stable throughout the decade; among the female patients it rose significantly, from 71.7% in 1981 to 75.3% in 1991 (p < 0.01). The perforation rates increased significantly among both the female and male patients (p < 0.01), whereas the mean length of stay decreased (p < 0.05). Despite sex-related differences in the accuracy rates, the male and female patients had similar in-hospital death rates and mean lengths of stay. The institutional diagnostic accuracy rates, as determined from data for 1989-90 to 1991-92, ranged from 50.0% to 96.7%. Multivariate analyses of 27,189 confirmed cases of appendicitis at 175 hospitals revealed that perforation was a strong predictor of in-hospital death (odds ratio [OR] 2.46, 95% confidence interval [CI] 1.24 to 4.88), but comorbidity was the strongest predictor (OR 11.50, 95% CI 5.96 to 22.10). For each 10% increase in the diagnostic accuracy rate, the perforation rate increased 14% (OR 1.14, 95% CI 1.10 to 1.19), but the accuracy rate was not significantly related to the in-hospital death rate or the length of stay.
A higher diagnostic accuracy rate is associated with more perforated appendixes. Although perforation itself leads to adverse outcomes, a higher accuracy rate does not. This suggests that hospitals with higher accuracy rates incur more perforations, but, with close observation, timely laparotomy and the use of modern antibiotics, these patients have favourable outcomes. This contrasts with adverse effects of perforation among patients at high risk for perforation (especially very young children and elderly people) in centres at all accuracy levels. The variation in hospitals' diagnostic accuracy rates suggests that some proportion of appendectomies could be safely avoided.
检验如下假设，即采用现代诊断方法和抗生素，在疑似阑尾炎病例中更保守地使用手术不会导致确诊病例的短期并发症发生率增加。
基于人群的观察性研究，使用行政数据。
1981年4月1日至1992年3月31日期间进行原发性阑尾切除术的安大略省所有医院。
研究期间因原发性阑尾切除术入院的所有126,815名患者。
诊断准确率（以急性阑尾炎作为主要诊断）、穿孔率、住院死亡率和住院时间。
在整个十年中，男性患者的诊断准确率保持稳定；女性患者的诊断准确率显著上升，从1981年的71.7%升至1991年的75.3%（p<0.01）。男性和女性患者的穿孔率均显著上升（p<0.01），而平均住院时间缩短（p<0.05）。尽管准确率存在性别差异，但男性和女性患者的住院死亡率和平均住院时间相似。根据1989 - 90年至1991 - 92年的数据确定的机构诊断准确率在50.0%至96.7%之间。对175家医院的27,189例确诊阑尾炎病例进行的多变量分析显示，穿孔是住院死亡的有力预测因素（比值比[OR]2.46，95%置信区间[CI]1.24至4.88），但合并症是最强的预测因素（OR 11.50，95%CI 5.96至22.10）。诊断准确率每提高10%，穿孔率增加14%（OR 1.14，95%CI 1.10至1.19），但准确率与住院死亡率或住院时间无显著相关性。
较高的诊断准确率与更多的阑尾穿孔相关。虽然穿孔本身会导致不良后果，但较高的准确率并不会。这表明诊断准确率较高的医院阑尾穿孔更多，但通过密切观察、及时剖腹手术和使用现代抗生素，这些患者的预后良好。这与所有准确率水平的中心中穿孔高危患者（尤其是非常年幼的儿童和老年人）的穿孔不良影响形成对比。医院诊断准确率的差异表明，一定比例的阑尾切除术可以安全避免。
