Background
Effective health care requires rapid and effective decision-making. In ideal circumstances this implies careful consideration of key factors before the decision is made. Important factors to consider, for example, are the safety of diagnostic and treatment alternatives as well as the impact of the decisions taken on patient safety, quality-of-life, health economics and, in some cases, long-term survival. It is difficult, however, to base each individual decision on a complete analysis of all relevant factors, and in the emergency department many decisions are probably made based on the outcome of previous similar cases - "pattern recognition".
Acute appendicitis is one of the most common acute abdominal conditions. The decision to perform surgical exploration in suspected appendicitis involves diagnostic accuracy, patient age and co-morbidity, patient's own wishes, the surgeon's core medical values, expected natural course of non-operative treatment and priority considerations regarding the use of limited resources. The decision to operate a patient with suspected appendicitis can therefore serve as a model to study how various clinical factors are ranked in surgical decision-making.
Under optimal circumstances, surgeons aim for high sensitivity, with as few neglected appendicitis diagnoses as possible. At the same time one hopes for high specificity, with as few negative explorations as possible. It has recently been questioned if it's enough just to make the right diagnosis, or if it's also necessary to evaluate whether it's a gangrenous appendicitis that may heal itself or if it's a progressive appendicitis with a high risk for perforation. The surgeon is thus expected not only to make a correct diagnosis but also to stage the condition based on rather limited facts. How do surgeons think when making these decisions? Do objective clinical findings, such as radiology and laboratory results, have greater impact on decision-making than "soft" clinical variables? Is there adherence to both experience and to evidence-based surgery?
There are several examples of studies comparing different means of diagnosis in appendicitis, but few have identified the intellectual process involved in the decision to perform appendectomy. The purpose of this study was to investigate parameters that surgeons consider significant in decision-making in cases of suspected appendicitis.