Awareness and Utilization of the RIPASA Score for Acute Appendicitis Among Emergency and Surgical Physicians: A Cross-Sectional Study

Awareness and Utilization of the RIPASA Score for Acute Appendicitis Among Emergency and Surgical Physicians: A Cross-Sectional Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Awareness and Utilization of the RIPASA Score for Acute Appendicitis Among Emergency and Surgical Physicians: A Cross-Sectional Study Hassan Uthman U Alghamdi, Abdulhakam Ahmed, Mohamed Mehdi Makhbouche, and 8 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8694062/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Accurate diagnosis of acute appendicitis remains challenging, and several clinical scoring systems have been developed to support decision-making. The RIPASA score has demonstrated good diagnostic performance, particularly in Asian and Middle Eastern populations; however, data on clinicians’ awareness and real-world utilization are limited. Objective: To assess awareness, utilization, and perceived barriers to the use of the RIPASA score among emergency and surgical physicians. Methods: A single-center cross-sectional survey was conducted at a tertiary care hospital in Saudi Arabia. Physicians involved in the assessment or management of suspected acute appendicitis were invited to complete an anonymous electronic questionnaire. Duplicate and incomplete responses were excluded. Descriptive statistics were used to summarize responses, and comparisons between specialties were performed using the Chi-square test. Results: Of 124 responses received, 104 were included in the final analysis after exclusion of incomplete or irrelevant questionnaires. Overall, 85.6% of participants were aware of the RIPASA score, while 52.9% reported using it in clinical practice. Surgeons reported significantly higher utilization of the RIPASA score compared with emergency medicine physicians (χ² = 6.58, p = 0.038). The most commonly reported barriers were unfamiliarity with the score (49.0%), lack of training (35.6%), and perceived time constraints (19.2%). Conclusion: Despite high awareness, utilization of the RIPASA score remains moderate, with significant variation between emergency and surgical physicians. Targeted training and integration of RIPASA into clinical workflows may improve its adoption and support more standardized diagnosis of acute appendicitis. RIPASA score acute appendicitis emergency medicine surgery diagnostic scoring systems survey Figures Figure 1 Introduction Acute appendicitis is one of the most common causes of acute abdominal pain presenting to emergency departments worldwide. ( 1 ) Despite advances in imaging modalities, the diagnosis of acute appendicitis continues to pose a clinical challenge, particularly in early or atypical presentations. Delayed or inaccurate diagnosis may result in complications such as perforation, while overdiagnosis can lead to unnecessary imaging, increased healthcare costs, and negative appendectomy rates. To support clinical decision-making, several clinical scoring systems have been proposed to improve diagnostic accuracy in acute appendicitis ( 2 – 7 ), including the Alvarado, AIR, and RIPASA scores ( 2 , 3 ). Among these, the RIPASA score incorporates demographic characteristics, clinical symptoms, physical examination findings, and laboratory parameters, and has demonstrated favorable diagnostic accuracy in multiple studies, particularly in Asian and Middle Eastern populations. Previous research has shown that the RIPASA score may outperform traditional scoring systems in certain populations. While the diagnostic performance of the RIPASA score has been widely evaluated, most existing studies have focused on sensitivity, specificity, and predictive values using clinical or histopathological outcomes as reference standards. In contrast, limited attention has been given to clinicians’ awareness of the RIPASA score and its real-world utilization in daily clinical practice. The successful implementation of any clinical decision tool depends not only on its diagnostic accuracy but also on clinicians’ familiarity with the tool, perceived usefulness, and integration into routine workflows. Emergency medicine physicians and surgeons play complementary yet distinct roles in the assessment and management of suspected acute appendicitis. Differences in clinical priorities, workflow pressures, and reliance on imaging may influence the adoption of structured diagnostic scoring systems ( 8 , 9 ). To date, there is a lack of published data specifically examining awareness and utilization of the RIPASA score among emergency and surgical physicians, representing an important gap in the literature. Therefore, this study aimed to assess the level of awareness, utilization, and perceived barriers to the use of the RIPASA score among emergency and surgical physicians at a tertiary care hospital in Saudi Arabia. Methods Study Design and Setting This study was designed as a single-center cross-sectional survey, conducted at a tertiary care hospital in Saudi Arabia that provides emergency and surgical services to a wide catchment area. The study was conducted over a defined data collection period using an electronic questionnaire. This study was reported in accordance with the STROBE statement. ( 11 ) Study Population The study targeted physicians involved in the assessment, referral, or management of patients with suspected acute appendicitis. Eligible participants included: Emergency medicine physicians General surgeons Pediatric surgeons Internal medicine physicians involved in acute care Residents working in the above specialties Physicians with less than six months of clinical experience and medical students were excluded from the study. Sampling and Recruitment Participants were recruited using a convenience sampling method. The survey link was distributed electronically through institutional communication channels and professional messaging platforms. Participation was voluntary, and no incentives were offered. To maximize response rates, reminders were sent periodically during the data collection period. The achieved sample size was considered adequate for descriptive and comparative analyses. Data Collection Tool Data were collected using a structured, self-administered electronic questionnaire developed after reviewing relevant literature on appendicitis scoring systems and clinical decision tools. The questionnaire consisted of approximately 20 items divided into four main sections: 1. Demographic and professional characteristics (e.g., specialty and years of clinical experience) 2. Awareness and knowledge of the RIPASA score 3. Utilization of the RIPASA score in clinical practice 4. Perceived barriers to the use of the RIPASA score The questionnaire was designed to be concise and required approximately 5–7 minutes to complete. The questionnaire was reviewed for content validity and clarity before data collection. It was distributed to 15 consultant physicians from emergency medicine and surgical specialties who were not included in the final study sample. Feedback was obtained regarding the relevance, clarity, and comprehensiveness of the questionnaire items. Minor modifications were made based on their feedback to improve wording and ensure alignment with the study objectives. The final version of the questionnaire was pilot-tested to ensure ease of completion and feasibility. Data Collection Procedure The survey was administered electronically to ensure ease of access and anonymity. No identifying information was collected. Responses were automatically recorded in a secure database. Duplicate entries and questionnaires with substantial missing data were excluded during data cleaning before analysis. Statistical Analysis For comparative analysis, participants were grouped into emergency physicians and surgical physicians, as these specialties are directly involved in the diagnostic and management pathway of suspected acute appendicitis. Other specialties, including internal medicine, were excluded from comparative analyses due to limited involvement in surgical decision-making and a smaller sample size. Data were analyzed using IBM SPSS Statistics (IBM Corp., Armonk, NY, USA). Descriptive statistics were used to summarize participant characteristics and survey responses. Categorical variables were presented as frequencies and percentages. Comparisons between emergency medicine and surgical physicians regarding RIPASA utilization were performed using the Chi-square test. A p-value < 0.05 was considered statistically significant. Results A target sample size of approximately 150 responses was planned for this study. A total of 124 responses were received during the data collection period. After data cleaning, 20 questionnaires were excluded due to duplication or incomplete and irrelevant responses that precluded meaningful descriptive or comparative analysis. Consequently, 104 participants were included in the final analysis. Participant Characteristics The demographic and professional characteristics of the participants are summarized in Table 1 . More than half of the respondents (54.8%) had 1–5 years of clinical experience, followed by 6–10 years (27.9%), while 17.3% had more than 10 years of experience. Participants represented emergency medicine, surgical specialties, and other related disciplines involved in the management of suspected acute appendicitis. Table 1 Demographic and Professional Characteristics of Participants (n = 104) Variable Category n (%) Years of clinical experience 1–5 years 57 (54.8) 6–10 years 29 (27.9) > 10 years 18 (17.3) Specialty Emergency Medicine 36 (34.6) Surgery* 56 (53.8) Other specialties† 12 (11.6) * Surgery includes general surgery and pediatric surgery. †Other specialties included internal medicine only. Awareness of the RIPASA Score Overall, 85.6% (n = 89) of participants reported being aware of the RIPASA score, whereas 14.4% (n = 15) indicated that they were not familiar with it. Awareness and utilization-related responses are detailed in Table 2 . Utilization of the RIPASA Score Despite the high level of awareness, only 52.9% (n = 55) of respondents reported using the RIPASA score in their clinical practice, while 47.1% (n = 49) did not routinely use the score (Table 2 ). Table 2 Awareness and Utilization of the RIPASA Score Among Participants (n = 104) Variable Response n (%) Awareness of the RIPASA score Yes 89 (85.6) No 15 (14.4) Use of the RIPASA score in clinical practice Yes 55 (52.9) No 49 (47.1) Data are presented as number (percentage). Percentages are calculated based on the total study population (n = 104). Most participants were aware of the RIPASA score (85.6%), while just over half reported using it in clinical practice (52.9%). Comparison of Utilization by Specialty When comparing emergency physicians with all surgical participants (including residents and specialists), the utilization of RIPASA scores was significantly higher among surgical physicians (60.0%) compared with emergency physicians (41.7%) (χ² = 6.58, p = 0.038). Table 3 summarizes the comparison between emergency physicians and surgical physicians. The association between physician specialty and RIPASA score utilization is further illustrated in Fig. 1 , which demonstrates higher utilization among surgeons compared with emergency medicine physicians. Table 3 Comparison of RIPASA score utilization between emergency physicians and surgical physicians (all levels). Specialty group Use RIPASA – Yes Use RIPASA – No Total Emergency physicians 15 (41.7%) 21 (58.3%) 36 Surgery (all levels) * 36 (60.0%) 24 (40.0%) 60 Chi-square test p = 0.038 Data are presented as number (percentage). Percentages are calculated by row. * Surgery (all levels) includes surgical specialists and surgical residents across all surgical specialties. Perceived Barriers to Using the RIPASA Score Reported barriers to the use of the RIPASA score are summarized in Table 4 . The most frequently cited barrier was unfamiliarity with the score (49.0%), followed by lack of training (35.6%) and the perception that the score is time-consuming (19.2%). A smaller proportion of participants reported limited availability of the score or related protocols (5.8%). As participants were allowed to select more than one response, the total percentage exceeded 100%. Table 4 Reported Barriers to Using the RIPASA Score (n = 104) Barrier n (%) Unfamiliarity with the RIPASA score 51 (49.0) Lack of formal training 37 (35.6) Score perceived as time-consuming 20 (19.2) Not readily available / no local protocol 6 (5.8) Participants were allowed to select more than one response; therefore, percentages exceed 100%. Discussion This study provides insight into physicians’ awareness and real-world utilization of the RIPASA score in the assessment of suspected acute appendicitis. The main findings demonstrate that, despite a high level of awareness among participating physicians, actual utilization of the RIPASA score in clinical practice remains moderate. In addition, a statistically significant difference in utilization was observed across specialties, with surgeons reporting higher use than emergency medicine physicians. The observed discrepancy between awareness and utilization highlights an important implementation gap. Previous studies have evaluated the performance and applicability of the RIPASA score in different populations (12). In particular, in Asian and Middle Eastern populations, awareness alone does not appear to be sufficient to ensure consistent adoption in daily clinical practice. This finding is consistent with broader literature on clinical decision tools, which suggests that validated scoring systems are often underutilized due to workflow constraints and limited integration into routine practice. ( 9 , 10 ) The significantly higher utilization of RIPASA among surgeons compared with emergency medicine physicians may reflect differences in clinical roles and decision-making processes. Surgeons are often directly responsible for operative decisions and may therefore place greater emphasis on structured risk stratification tools when evaluating suspected appendicitis. In contrast, emergency physicians frequently manage high patient volumes and time-sensitive presentations, which may increase reliance on imaging modalities or clinical judgment rather than formal scoring systems. This difference in practice patterns may partially explain the lower utilization observed in the emergency medicine group, as illustrated by the stacked bar chart and supported by the statistically significant association between specialty and RIPASA use. Analysis of perceived barriers further supports these findings. Unfamiliarity with the RIPASA score and lack of formal training were the most commonly reported obstacles, suggesting that many clinicians may not feel sufficiently confident to apply the score consistently. Additionally, a notable proportion of participants perceived the RIPASA score as time-consuming, which may limit its use in busy emergency settings. These barriers are potentially modifiable and point toward practical strategies for improving adoption, such as targeted educational interventions, incorporation of the score into local clinical protocols, and integration into electronic medical record systems to reduce time burden. The findings of this study have important clinical implications. Improving the utilization of validated scoring systems such as RIPASA may help standardize the initial assessment of suspected acute appendicitis, reduce unnecessary imaging, and support more consistent referral and management decisions. From an educational perspective, incorporating RIPASA training into emergency and surgical curricula may improve familiarity and confidence in its use. At an institutional level, embedding the score into clinical pathways or electronic order sets could facilitate routine application and overcome time-related barriers. Limitations Several limitations should be acknowledged. First, the study was conducted at a single center, which may limit the generalizability of the findings to other settings or healthcare systems. Second, the reliance on self-reported data may introduce recall or social desirability bias. Third, the study focused on awareness and utilization rather than clinical outcomes, and therefore cannot determine whether increased use of RIPASA directly improves diagnostic accuracy or patient outcomes. Despite these limitations, the sample size was adequate for descriptive and comparative analyses, and the study addresses a notable gap in the literature regarding real-world use of the RIPASA score among emergency and surgical physicians. Conclusion Despite high awareness, utilization of the RIPASA score remains moderate, with significant variation between emergency and surgical physicians. Targeted training and integration of RIPASA into clinical workflows may improve its adoption and support more standardized diagnosis of acute appendicitis. Declarations Ethics Approval and Consent to Participate This study was conducted in accordance with the ethical standards of the institutional research committee and in compliance with the Declaration of Helsinki. Ethical approval was obtained from the Institutional Review Board of the participating hospital. Informed consent was obtained from all participants before participation in the survey. Consent to publish Not applicable. Competing interests The authors declare that they have no competing interests. Funding This research received no external funding. Author Contribution HUA and AA conceived the study. AA, HE, and RA performed data collection. AA conducted statistical analysis. MM, HYG, AB, AE, AAlw, BM, and MZ contributed to questionnaire design and validation. All authors drafted, revised, and approved the final manuscript. Data Availability The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. References Addiss DG, Shaffer N, Fowler BS, Tauxe RV. The epidemiology of appendicitis and appendectomy in the United States. Am J Epidemiol. 1990;132(5):910–25. Andersson M, Andersson RE. The Appendicitis Inflammatory Response score: a tool for the diagnosis of acute appendicitis that outperforms the Alvarado score. World J Surg. 2008;32(8):1843–9. Chong CF, Adi MI, Thien A, et al. Development of the RIPASA score: a new appendicitis scoring system for the diagnosis of acute appendicitis. Singap Med J. 2010;51(3):220–5. Chong CF, Thien A, Mackie AJ, et al. Comparison of RIPASA and Alvarado scores for the diagnosis of acute appendicitis. Singap Med J. 2011;52(5):340–5. Malik MU, Connelly TM, Awan F, et al. The RIPASA score is sensitive and specific for the diagnosis of acute appendicitis in a Western population. Int J Colorectal Dis. 2017;32(4):491–7. Chisthi MM, Ali A, Shahid A, et al. Diagnostic accuracy of RIPASA and AIR scores in acute appendicitis. BMC Emerg Med. 2022;22:88. Scheijmans JCG, Borgstein PJ, Puylaert JBCM, et al. Diagnostic accuracy of emergency physicians compared with structured assessment tools in suspected appendicitis. Eur J Trauma Emerg Surg. 2024;50(2):457–65. Bahta NNA, Simelane ZP, Bösenberg AT. Clinical decision rules for appendicitis are underutilized by surgeons: a cross-sectional survey. World J Surg. 2024;48(3):765–73. Xiong Y, Wang Y, Zhang Y, et al. Physician awareness and attitudes toward clinical decision support scoring systems: a cross-sectional survey. BMC Med Inf Decis Mak. 2022;22:178. von Elm E, Altman DG, Egger M, et al. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement. PLoS Med. 2007;4(10):e296. Di Saverio S, Podda M, De Simone B, et al. Diagnosis and treatment of acute appendicitis: 2020 update of the WSES Jerusalem guidelines. World J Emerg Surg. 2020;15:27. Additional Declarations No competing interests reported. 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specialty.\u003c/p\u003e","description":"","filename":"Picture1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8694062/v1/cecfe517f546b43a145c814f.jpg"},{"id":104404488,"identity":"c1a9f017-d839-4612-9913-47dd4751e2ae","added_by":"auto","created_at":"2026-03-11 12:20:23","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":782211,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8694062/v1/4004455b-e582-42b0-a769-ea9358265830.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Awareness and Utilization of the RIPASA Score for Acute Appendicitis Among Emergency and Surgical Physicians: A Cross-Sectional Study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eAcute appendicitis is one of the most common causes of acute abdominal pain presenting to emergency departments worldwide. (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) Despite advances in imaging modalities, the diagnosis of acute appendicitis continues to pose a clinical challenge, particularly in early or atypical presentations. Delayed or inaccurate diagnosis may result in complications such as perforation, while overdiagnosis can lead to unnecessary imaging, increased healthcare costs, and negative appendectomy rates.\u003c/p\u003e \u003cp\u003eTo support clinical decision-making, several clinical scoring systems have been proposed to improve diagnostic accuracy in acute appendicitis (\u003cspan additionalcitationids=\"CR3 CR4 CR5 CR6\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e), including the Alvarado, AIR, and RIPASA scores (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Among these, the RIPASA score incorporates demographic characteristics, clinical symptoms, physical examination findings, and laboratory parameters, and has demonstrated favorable diagnostic accuracy in multiple studies, particularly in Asian and Middle Eastern populations. Previous research has shown that the RIPASA score may outperform traditional scoring systems in certain populations.\u003c/p\u003e \u003cp\u003eWhile the diagnostic performance of the RIPASA score has been widely evaluated, most existing studies have focused on sensitivity, specificity, and predictive values using clinical or histopathological outcomes as reference standards. In contrast, limited attention has been given to clinicians\u0026rsquo; awareness of the RIPASA score and its real-world utilization in daily clinical practice. The successful implementation of any clinical decision tool depends not only on its diagnostic accuracy but also on clinicians\u0026rsquo; familiarity with the tool, perceived usefulness, and integration into routine workflows.\u003c/p\u003e \u003cp\u003eEmergency medicine physicians and surgeons play complementary yet distinct roles in the assessment and management of suspected acute appendicitis. Differences in clinical priorities, workflow pressures, and reliance on imaging may influence the adoption of structured diagnostic scoring systems (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). To date, there is a lack of published data specifically examining awareness and utilization of the RIPASA score among emergency and surgical physicians, representing an important gap in the literature. Therefore, this study aimed to assess the level of awareness, utilization, and perceived barriers to the use of the RIPASA score among emergency and surgical physicians at a tertiary care hospital in Saudi Arabia.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Design and Setting\u003c/h2\u003e \u003cp\u003e This study was designed as a single-center cross-sectional survey, conducted at a tertiary care hospital in Saudi Arabia that provides emergency and surgical services to a wide catchment area.\u003c/p\u003e \u003cp\u003eThe study was conducted over a defined data collection period using an electronic questionnaire. This study was reported in accordance with the STROBE statement. (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e)\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eStudy Population\u003c/h3\u003e\n\u003cp\u003eThe study targeted physicians involved in the assessment, referral, or management of patients with suspected acute appendicitis. Eligible participants included:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eEmergency medicine physicians\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eGeneral surgeons\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003ePediatric surgeons\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eInternal medicine physicians involved in acute care\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eResidents working in the above specialties\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003ePhysicians with less than six months of clinical experience and medical students were excluded from the study.\u003c/p\u003e\n\u003ch3\u003eSampling and Recruitment\u003c/h3\u003e\n\u003cp\u003eParticipants were recruited using a convenience sampling method. The survey link was distributed electronically through institutional communication channels and professional messaging platforms. Participation was voluntary, and no incentives were offered. To maximize response rates, reminders were sent periodically during the data collection period. The achieved sample size was considered adequate for descriptive and comparative analyses.\u003c/p\u003e\n\u003ch3\u003eData Collection Tool\u003c/h3\u003e\n\u003cp\u003eData were collected using a structured, self-administered electronic questionnaire developed after reviewing relevant literature on appendicitis scoring systems and clinical decision tools. The questionnaire consisted of approximately 20 items divided into four main sections:\u003c/p\u003e \u003cp\u003e1. Demographic and professional characteristics (e.g., specialty and years of clinical experience)\u003c/p\u003e \u003cp\u003e2. Awareness and knowledge of the RIPASA score\u003c/p\u003e \u003cp\u003e3. Utilization of the RIPASA score in clinical practice\u003c/p\u003e \u003cp\u003e4. Perceived barriers to the use of the RIPASA score\u003c/p\u003e \u003cp\u003eThe questionnaire was designed to be concise and required approximately 5\u0026ndash;7 minutes to complete.\u003c/p\u003e \u003cp\u003eThe questionnaire was reviewed for content validity and clarity before data collection. It was distributed to 15 consultant physicians from emergency medicine and surgical specialties who were not included in the final study sample. Feedback was obtained regarding the relevance, clarity, and comprehensiveness of the questionnaire items. Minor modifications were made based on their feedback to improve wording and ensure alignment with the study objectives.\u003c/p\u003e \u003cp\u003eThe final version of the questionnaire was pilot-tested to ensure ease of completion and feasibility.\u003c/p\u003e\n\u003ch3\u003eData Collection Procedure\u003c/h3\u003e\n\u003cp\u003eThe survey was administered electronically to ensure ease of access and anonymity. No identifying information was collected. Responses were automatically recorded in a secure database. Duplicate entries and questionnaires with substantial missing data were excluded during data cleaning before analysis.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eFor comparative analysis, participants were grouped into emergency physicians and surgical physicians, as these specialties are directly involved in the diagnostic and management pathway of suspected acute appendicitis. Other specialties, including internal medicine, were excluded from comparative analyses due to limited involvement in surgical decision-making and a smaller sample size.\u003c/p\u003e \u003cp\u003eData were analyzed using IBM SPSS Statistics (IBM Corp., Armonk, NY, USA). Descriptive statistics were used to summarize participant characteristics and survey responses. Categorical variables were presented as frequencies and percentages. Comparisons between emergency medicine and surgical physicians regarding RIPASA utilization were performed using the Chi-square test. A p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eA target sample size of approximately 150 responses was planned for this study. A total of 124 responses were received during the data collection period. After data cleaning, 20 questionnaires were excluded due to duplication or incomplete and irrelevant responses that precluded meaningful descriptive or comparative analysis. Consequently, 104 participants were included in the final analysis.\u003c/p\u003e\n\u003ch3\u003eParticipant Characteristics\u003c/h3\u003e\n\u003cp\u003eThe demographic and professional characteristics of the participants are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. More than half of the respondents (54.8%) had 1\u0026ndash;5 years of clinical experience, followed by 6\u0026ndash;10 years (27.9%), while 17.3% had more than 10 years of experience. Participants represented emergency medicine, surgical specialties, and other related disciplines involved in the management of suspected acute appendicitis.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDemographic and Professional Characteristics of Participants (n\u0026thinsp;=\u0026thinsp;104)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCategory\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYears of clinical experience\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u0026ndash;5 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e57 (54.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6\u0026ndash;10 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e29 (27.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;10 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e18 (17.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSpecialty\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEmergency Medicine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e36 (34.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSurgery*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e56 (53.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOther specialties\u0026dagger;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e12 (11.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003e \u003cem\u003e*\u003c/em\u003eSurgery includes general surgery and pediatric surgery.\u003c/p\u003e \u003cp\u003e\u0026dagger;Other specialties included internal medicine only.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eAwareness of the RIPASA Score\u003c/h2\u003e \u003cp\u003eOverall, 85.6% (n\u0026thinsp;=\u0026thinsp;89) of participants reported being aware of the RIPASA score, whereas 14.4% (n\u0026thinsp;=\u0026thinsp;15) indicated that they were not familiar with it. Awareness and utilization-related responses are detailed in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eUtilization of the RIPASA Score\u003c/h2\u003e \u003cp\u003eDespite the high level of awareness, only 52.9% (n\u0026thinsp;=\u0026thinsp;55) of respondents reported using the RIPASA score in their clinical practice, while 47.1% (n\u0026thinsp;=\u0026thinsp;49) did not routinely use the score (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAwareness and Utilization of the RIPASA Score Among Participants (n\u0026thinsp;=\u0026thinsp;104)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eResponse\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAwareness of the RIPASA score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e89 (85.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e15 (14.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUse of the RIPASA score in clinical practice\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e55 (52.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e49 (47.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eData are presented as number (percentage). Percentages are calculated based on the total study population (n\u0026thinsp;=\u0026thinsp;104).\u003c/p\u003e \u003cp\u003eMost participants were aware of the RIPASA score (85.6%), while just over half reported using it in clinical practice (52.9%).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eComparison of Utilization by Specialty\u003c/h2\u003e \u003cp\u003eWhen comparing emergency physicians with all surgical participants (including residents and specialists), the utilization of RIPASA scores was significantly higher among surgical physicians (60.0%) compared with emergency physicians (41.7%) (χ\u0026sup2; = 6.58, p\u0026thinsp;=\u0026thinsp;0.038). Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e summarizes the comparison between emergency physicians and surgical physicians.\u003c/p\u003e \u003cp\u003eThe association between physician specialty and RIPASA score utilization is further illustrated in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, which demonstrates higher utilization among surgeons compared with emergency medicine physicians.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of RIPASA score utilization between emergency physicians and surgical physicians (all levels).\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSpecialty group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUse RIPASA \u0026ndash; Yes\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eUse RIPASA \u0026ndash; No\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEmergency physicians\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e15 (41.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e21 (58.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSurgery (all levels) *\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e36 (60.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e24 (40.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e60\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eChi-square test\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003ep\u0026thinsp;=\u0026thinsp;0.038\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eData are presented as number (percentage). Percentages are calculated by row.\u003c/p\u003e \u003cp\u003e* Surgery (all levels) includes surgical specialists and surgical residents across all surgical specialties.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003ePerceived Barriers to Using the RIPASA Score\u003c/h2\u003e \u003cp\u003eReported barriers to the use of the RIPASA score are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e. The most frequently cited barrier was unfamiliarity with the score (49.0%), followed by lack of training (35.6%) and the perception that the score is time-consuming (19.2%). A smaller proportion of participants reported limited availability of the score or related protocols (5.8%). As participants were allowed to select more than one response, the total percentage exceeded 100%.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eReported Barriers to Using the RIPASA Score (n\u0026thinsp;=\u0026thinsp;104)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBarrier\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnfamiliarity with the RIPASA score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e51 (49.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLack of formal training\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e37 (35.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eScore perceived as time-consuming\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e20 (19.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNot readily available / no local protocol\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6 (5.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eParticipants were allowed to select more than one response; therefore, percentages exceed 100%.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study provides insight into physicians\u0026rsquo; awareness and real-world utilization of the RIPASA score in the assessment of suspected acute appendicitis. The main findings demonstrate that, despite a high level of awareness among participating physicians, actual utilization of the RIPASA score in clinical practice remains moderate. In addition, a statistically significant difference in utilization was observed across specialties, with surgeons reporting higher use than emergency medicine physicians.\u003c/p\u003e \u003cp\u003eThe observed discrepancy between awareness and utilization highlights an important implementation gap. Previous studies have evaluated the performance and applicability of the RIPASA score in different populations (12). In particular, in Asian and Middle Eastern populations, awareness alone does not appear to be sufficient to ensure consistent adoption in daily clinical practice. This finding is consistent with broader literature on clinical decision tools, which suggests that validated scoring systems are often underutilized due to workflow constraints and limited integration into routine practice. (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eThe significantly higher utilization of RIPASA among surgeons compared with emergency medicine physicians may reflect differences in clinical roles and decision-making processes. Surgeons are often directly responsible for operative decisions and may therefore place greater emphasis on structured risk stratification tools when evaluating suspected appendicitis. In contrast, emergency physicians frequently manage high patient volumes and time-sensitive presentations, which may increase reliance on imaging modalities or clinical judgment rather than formal scoring systems. This difference in practice patterns may partially explain the lower utilization observed in the emergency medicine group, as illustrated by the stacked bar chart and supported by the statistically significant association between specialty and RIPASA use.\u003c/p\u003e \u003cp\u003eAnalysis of perceived barriers further supports these findings. Unfamiliarity with the RIPASA score and lack of formal training were the most commonly reported obstacles, suggesting that many clinicians may not feel sufficiently confident to apply the score consistently. Additionally, a notable proportion of participants perceived the RIPASA score as time-consuming, which may limit its use in busy emergency settings. These barriers are potentially modifiable and point toward practical strategies for improving adoption, such as targeted educational interventions, incorporation of the score into local clinical protocols, and integration into electronic medical record systems to reduce time burden.\u003c/p\u003e \u003cp\u003eThe findings of this study have important clinical implications. Improving the utilization of validated scoring systems such as RIPASA may help standardize the initial assessment of suspected acute appendicitis, reduce unnecessary imaging, and support more consistent referral and management decisions. From an educational perspective, incorporating RIPASA training into emergency and surgical curricula may improve familiarity and confidence in its use. At an institutional level, embedding the score into clinical pathways or electronic order sets could facilitate routine application and overcome time-related barriers.\u003c/p\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eSeveral limitations should be acknowledged. First, the study was conducted at a single center, which may limit the generalizability of the findings to other settings or healthcare systems. Second, the reliance on self-reported data may introduce recall or social desirability bias. Third, the study focused on awareness and utilization rather than clinical outcomes, and therefore cannot determine whether increased use of RIPASA directly improves diagnostic accuracy or patient outcomes. Despite these limitations, the sample size was adequate for descriptive and comparative analyses, and the study addresses a notable gap in the literature regarding real-world use of the RIPASA score among emergency and surgical physicians.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":" \u003cp\u003eDespite high awareness, utilization of the RIPASA score remains moderate, with significant variation between emergency and surgical physicians. Targeted training and integration of RIPASA into clinical workflows may improve its adoption and support more standardized diagnosis of acute appendicitis.\u003c/p\u003e \u003c/p\u003e\u003cp\u003e "},{"header":"Declarations","content":"\u003ch2\u003eEthics Approval and Consent to Participate\u003c/h2\u003e \u003cp\u003e This study was conducted in accordance with the ethical standards of the institutional research committee and in compliance with the Declaration of Helsinki. Ethical approval was obtained from the Institutional Review Board of the participating hospital. Informed consent was obtained from all participants before participation in the survey.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent to publish\u003c/strong\u003e \u003cp\u003eNot applicable.\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eCompeting interests\u003c/h2\u003e \u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eThis research received no external funding.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eHUA and AA conceived the study. AA, HE, and RA performed data collection. AA conducted statistical analysis. MM, HYG, AB, AE, AAlw, BM, and MZ contributed to questionnaire design and validation. All authors drafted, revised, and approved the final manuscript.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAddiss DG, Shaffer N, Fowler BS, Tauxe RV. The epidemiology of appendicitis and appendectomy in the United States. Am J Epidemiol. 1990;132(5):910\u0026ndash;25.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAndersson M, Andersson RE. The Appendicitis Inflammatory Response score: a tool for the diagnosis of acute appendicitis that outperforms the Alvarado score. World J Surg. 2008;32(8):1843\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChong CF, Adi MI, Thien A, et al. Development of the RIPASA score: a new appendicitis scoring system for the diagnosis of acute appendicitis. Singap Med J. 2010;51(3):220\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChong CF, Thien A, Mackie AJ, et al. Comparison of RIPASA and Alvarado scores for the diagnosis of acute appendicitis. Singap Med J. 2011;52(5):340\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMalik MU, Connelly TM, Awan F, et al. The RIPASA score is sensitive and specific for the diagnosis of acute appendicitis in a Western population. Int J Colorectal Dis. 2017;32(4):491\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChisthi MM, Ali A, Shahid A, et al. Diagnostic accuracy of RIPASA and AIR scores in acute appendicitis. BMC Emerg Med. 2022;22:88.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eScheijmans JCG, Borgstein PJ, Puylaert JBCM, et al. Diagnostic accuracy of emergency physicians compared with structured assessment tools in suspected appendicitis. Eur J Trauma Emerg Surg. 2024;50(2):457\u0026ndash;65.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBahta NNA, Simelane ZP, B\u0026ouml;senberg AT. Clinical decision rules for appendicitis are underutilized by surgeons: a cross-sectional survey. World J Surg. 2024;48(3):765\u0026ndash;73.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eXiong Y, Wang Y, Zhang Y, et al. Physician awareness and attitudes toward clinical decision support scoring systems: a cross-sectional survey. BMC Med Inf Decis Mak. 2022;22:178.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003evon Elm E, Altman DG, Egger M, et al. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement. PLoS Med. 2007;4(10):e296.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDi Saverio S, Podda M, De Simone B, et al. Diagnosis and treatment of acute appendicitis: 2020 update of the WSES Jerusalem guidelines. World J Emerg Surg. 2020;15:27.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":true,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"RIPASA score, acute appendicitis, emergency medicine, surgery, diagnostic scoring systems, survey","lastPublishedDoi":"10.21203/rs.3.rs-8694062/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8694062/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eBackground: Accurate diagnosis of acute appendicitis remains challenging, and several clinical scoring systems have been developed to support decision-making. The RIPASA score has demonstrated good diagnostic performance, particularly in Asian and Middle Eastern populations; however, data on clinicians’ awareness and real-world utilization are limited.\u003cbr\u003e\n \u003cstrong\u003eObjective:\u003c/strong\u003e To assess awareness, utilization, and perceived barriers to the use of the RIPASA score among emergency and surgical physicians.\u003cbr\u003e\n \u003cstrong\u003eMethods:\u003c/strong\u003e A single-center cross-sectional survey was conducted at a tertiary care hospital in Saudi Arabia. Physicians involved in the assessment or management of suspected acute appendicitis were invited to complete an anonymous electronic questionnaire. Duplicate and incomplete responses were excluded. Descriptive statistics were used to summarize responses, and comparisons between specialties were performed using the Chi-square test.\u003cbr\u003e\n \u003cstrong\u003eResults:\u003c/strong\u003e Of 124 responses received, 104 were included in the final analysis after exclusion of incomplete or irrelevant questionnaires.\u003c/p\u003e\n\u003cp\u003eOverall, 85.6% of participants were aware of the RIPASA score, while 52.9% reported using it in clinical practice. Surgeons reported significantly higher utilization \u003cstrong\u003eof the RIPASA score\u003c/strong\u003e compared with emergency medicine physicians (χ² = 6.58, p = 0.038). The most commonly reported barriers were unfamiliarity with the score (49.0%), lack of training (35.6%), and perceived time constraints (19.2%).\u003cbr\u003e\n \u003cstrong\u003eConclusion:\u003c/strong\u003e Despite high awareness, utilization of the RIPASA score remains moderate, with significant variation between emergency and surgical physicians. Targeted training and integration of RIPASA into clinical workflows may improve its adoption and support more standardized diagnosis of acute appendicitis.\u003c/p\u003e","manuscriptTitle":"Awareness and Utilization of the RIPASA Score for Acute Appendicitis Among Emergency and Surgical Physicians: A Cross-Sectional Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-03 16:06:05","doi":"10.21203/rs.3.rs-8694062/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"92614035-d10c-4602-84d7-8edcc0cf2517","owner":[],"postedDate":"February 3rd, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-03-09T14:27:19+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-03 16:06:05","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8694062","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8694062","identity":"rs-8694062","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}