Changes

July 2025 — minor update. Updated information on prevalence of recurrence after non-surgical management and appendiceal carcinoma to the differential diagnosis. 

Update

Goals

To support primary healthcare professionals to:

• Be aware when to suspect a diagnosis of appendicitis.
• Fully assess a person with suspected appendicitis to guide management.
• Arrange urgent hospital admission for people with suspected appendicitis.

Outcome measures

No outcome measures were found during the review of this topic.

Audit criteria

No audit criteria were found during the review of this topic.

QOF indicators

No QOF indicators were found during the review of this topic.

QIPP - Options for local implementation

No QIPP plans were found for this topic.

NICE Quality standards

No NICE quality standards were found during the review of this topic.

What is it?

• Appendicitis describes an acute inflammation of the appendix [Téoule, 2020; Moris, 2021; BMJ Best Practice, 2023].
  • The appendix is a small, narrow tube (about 6–10 cm long) that is connected to the caecum (the proximal part of the large intestine, just before the colon) [Gorter, 2016].
  • Its precise function is not fully understood. It has a high concentration of gut-associated lymphoid tissue (GALT), and may act as a reservoir for normal gut flora, allowing the large bowel microbiome to recover after enteric infections [Rentea, 2017; Stringer, 2017].

What causes it?

The aetiology and pathogenesis of acute appendicitis remain largely unknown, but it is thought to be caused by luminal obstruction in about 50% of cases [Gorter, 2016; Rentea, 2017].

• The main causes of luminal obstruction are thought to be faecolith (hard mass of faecal matter), calculi, lymphoid hyperplasia during an infection, impacted stool, foreign body, or rarely, appendiceal or caecal tumour [Naar, 2020; Moris, 2021; BMJ Best Practice, 2023]. There may be underlying:
  • Infection — usually with aerobic and anaerobic bacteria, such as Escherichia coli and Bacteroides spp. [Moris, 2021; BMJ Best Practice, 2023].
  • Malignancy (rare) — there may be an underlying neuroendocrine tumour of the appendix (carcinoid), adenocarcinoma, or mucinous cystadenoma in 0.5% to 1.7% of people with appendicitis [Naar, 2020].
• Luminal obstruction leads to distension of the appendix owing to increased mucus production, bacterial overgrowth, and suppurative inflammation. This results in impaired lymphatic and venous drainage from the appendix, with eventual ischaemia and necrosis, and potential perforation [Gil, 2023; Moris, 2021; Gil, 2023].
• Emerging research has suggested that parasitic infection, schistosomal infection, and neuroimmune mechanisms may also be related to the aetiology of acute appendicitis [BMJ Best Practice, 2023].

What are the risk factors?

• Risk factors for appendicitis include:
  • Genetics — a positive family history is associated with a nearly three-fold increased risk of appendicitis [Rentea, 2017].
  • Environmental factors — there is a typically seasonal presentation with peaks in the summer months [Rentea, 2017].
  • Age — it is most common between the ages of 10–30 years but can occur at any age, with the highest incidence in children and adolescence (although it is rare before the age of 2 years; peak incidence appears to be among 15 to 19-year-olds) [Blok, 2021; BMJ Best Practice, 2023; Gil, 2023].
  • Male sex — it is slightly more common in men than women, with a male to female ratio of 1.4 to 1 [Moris, 2021; BMJ Best Practice, 2023]. Men may be at increased risk of perforated appendicitis [Moris, 2021], but women may be at higher life time risk of appendectomy [Téoule, 2020].
  • Frequent antibiotic use — a balance of microbial gut flora is important for prevention of infection and digestion. Frequent use of antibiotics leads to imbalance of gut flora that may eventually cause a modified response to viral infection, thereby triggering appendicitis [BMJ Best Practice, 2023].
  • Smoking — there is an increased incidence of acute appendicitis in smokers compared with non-smokers, and children exposed to passive smoking have a significantly increased incidence of acute appendicitis [BMJ Best Practice, 2023].
  • Socioeconomic factors — there appears to be a higher risk in people with a lower income and lower educational attainment [Moris, 2021].

How common is it?

Acute appendicitis is the most common abdominal surgical emergency in the world [Moris, 2021], with around 50,000 acute appendicectomies performed annually in the UK [Baird, 2017].

• Appendicitis is one of the most common causes of acute abdominal pain in children and adults [Di Saverio, 2020; Téoule, 2020].
  • Globally, the annual incidence is approximately 100 cases per 100,000 in the adult population [Moris, 2021] and around 83 to 120 cases per 100,000 among children [Blok, 2021; Gil, 2023].
    • The lifetime incidence appears to be higher among men (8.6%) compared with women (6.7%) [Moris, 2021].
    • A European Association of Endoscopic Surgery (EAES) consensus document notes further variation in incidence with ethnicity, obesity, and season of the year [Gorter, 2016].
• Acute appendicitis appears to be most frequent during the second and third decades of life, whereas children 9 years or younger and older adults have the lowest incidence [Fugazzola, 2020; Moris, 2021].
  • Appendicitis is identified as the cause of acute abdominal pain in approximately 15% of those aged 50 years or older, compared to nearly 30% among younger people [Fugazzola, 2020].
  • Acute appendicitis is very rare in children aged under 1 year [Wickramasinghe, 2021].
• In pregnancy, appendicitis is the most common non-obstetric surgical emergency, occurring in one in 500–600 pregnancies, most commonly presenting in the second trimester [Baird, 2017].
• It is estimated that approximately 30% of adult and pediatric patients with appendicitis present with complicated appendicitis [Kumar, 2024].

What is the prognosis?

Although the natural progression of acute appendicitis results in perforation, not all cases follow this course, as some resolve spontaneously [Di Saverio, 2020].

• There is growing evidence that perforation is not the inevitable result of acute appendicitis, and resolution may be a common event, such that initial non-operative management may be appropriate for selected people with uncomplicated acute appendicitis [Di Saverio, 2020].
  • An Italian retrospective cohort study of 16,544 consecutive hospital admissions for acute appendicitis described a relapse rate of 23.1% among the small proportion (5.34%) managed non-operatively, with a new episode of acute appendicitis occurring after a median of 32 days, leading to surgical treatment in the majority of cases (89%) [Ceresoli, 2016].
• When appendicitis is treated in a timely fashion, the prognosis is generally good [BMJ Best Practice, 2023].
• Mortality and morbidity rates may be related to the stage of disease at operation, with improved outcomes among those who underwent appendectomy within 16 hours of presentation, compared with those who underwent appendectomy 16 to 24 hours after presentation [Gil, 2023].
  • A Swedish retrospective cohort study of patients undergoing appendicectomy found a case fatality rate of 0.8 per 1000 procedures for non-perforated appendicitis, compared with 5.1 per 1000 procedures for perforated appendicitis, suggesting mortality and morbidity rates are related to the stage of disease at operation [Blomqvist, 2001].
• Elderly people with appendicitis are burdened by significantly higher mortality and morbidity rates [Fugazzola, 2020].
  • The risk of mortality in those aged 65 years or older may be up to 8%, compared with a risk of up to 1% among younger people.
  • Complicated appendicitis rates range from 18 to 70% in those aged 65 years or older, compared with 3 to 29% among people aged under 65 years.
• Expert opinion in a review article notes that recurrent appendicitis is possible if a long appendix stump is left in situ following appendicectomy [BMJ Best Practice, 2023].

What are the complications?

Appendicitis may be uncomplicated (non-perforating) or complicated (perforating) [Moris, 2021].

• Perforation is defined by a visible hole in the appendix, an appendicolith (calcified deposit within the appendix) free within the abdomen, or the presence of a well-formed abscess or frank pus in the abdomen [Gil, 2023]. It may develop within 24 hours of symptom onset [Moris, 2021].
  • The rate of perforation varies from 16–40%, with a higher frequency occurring in younger age groups and in people aged over 50 years [Di Saverio, 2020]. Increasing risks may correlate with younger aged children given their inability to articulate their symptoms [BMJ Best Practice, 2023].
  • Elderly people are more at risk of vascular sclerosis of the appendix and narrowing of the lumen by fibrosis which may weaken the appendix tissue and increase perforation susceptibility [Fugazzola, 2020].
  • Other risk factors for perforation include three or more comorbid conditions, male sex, and time from symptom onset to diagnosis and surgery [Synder, 2018].
  • Appendiceal perforation is associated with increased morbidity and mortality compared with non-perforating acute appendicitis, with possible increases in length of hospital stay, extended antibiotic administration, and more severe post-operative complications [Synder, 2018], and a mortality rate of about 5% [Di Saverio, 2020].
• A delay or misdiagnosis of appendicitis can result in additional severe complications from perforation, such as abscess formation, sepsis, and intra-abdominal adhesions [Kabir, 2017; BMJ Best Practice, 2023]:
  • Appendix mass — the inflamed appendix becomes walled off by omentum (a layer of peritoneum) and surrounding viscera to form an inflammatory mass [Stringer, 2017].
  • Appendix abscess — an appendix mass may resolve spontaneously or progress to form a localized abscess [Gorter, 2016; Di Saverio, 2020].
  • Generalized peritonitis — a potentially life-threatening infection that results from the release of purulent material from a perforation into the peritoneal cavity [BMJ Best Practice, 2023; Moris, 2021].
  • Sepsis — perforation can lead to sepsis and occurs in 17–32% of people with acute appendicitis [Synder, 2018]. See the CKS topic on Sepsis for more information.
  • Bowel obstruction — may be a further complication of perforation, and may follow the development of intra-abdominal adhesions [Kabir, 2017; Synder, 2018].
• In pregnancy, possible complications of acute appendicitis include an increased risk of fetal loss and pre-term delivery [Baird, 2017; Téoule, 2020; BMJ Best Practice, 2023].
• Post-operative complications may include [BMJ Best Practice, 2023; Gil, 2023]:
  • Wound infection and intra-abdominal abscess are potential complications associated with appendicectomy — laparoscopic appendicectomy has been associated with lower risk of surgery related complications.
  • The usual frequency of complication after laparoscopic appendectomy ranges from 4 to 8.7% [Bertrand, 2021].
  • The risk of complications may be higher among the elderly, including an increase in post-operative mortality, morbidity, and longer length of hospital stay [Fugazzola, 2020].
  • Stump appendicitis is a rare complication occurring in approximately 0.25% of people post-laparoscopic appendicectomy.
  • Malignancy — appendiceal malignancy is a rare post-operative complication, estimated to be identified in around 0.5% to 1.7% of surgical specimens [Naar, 2020; Téoule, 2020].
• Bowel cancer risks may be elevated among people with appendicitis that is managed non-operatively [Téoule, 2020; BMJ Best Practice, 2023].

When should I suspect a diagnosis of appendicitis?

Suspect a diagnosis of acute appendicitis if there are suggestive clinical features on history and examination. Establishing a diagnosis may be challenging, as it may present atypically and vary in severity.

• Take a full history, including current medication use.
• Ask about typical symptoms:
  • Abdominal pain (common).
    • Periumbilical or epigastric pain that worsens, and migrates to the right lower quadrant over 24–48 hours.
    • Often worsened by movement (such as coughing and driving over uneven roads).
    • Note: a history of sudden relief of pain may indicate appendiceal perforation.
  • Fever (often low grade), general malaise, and anorexia.
  • Nausea and vomiting.
  • Constipation (or sometimes diarrhoea).
  • Note: be aware of the small risk of 'stump appendicitis' in people with a previous history of appendicectomy, if the whole appendix has not been resected.
• Examine the person:
  • Check for facial flushing, dry tongue, halitosis, low-grade fever (less than 38°C), and/or tachycardia.
  • Assess for tenderness in the right lower quadrant on abdominal examination.
    • The site of maximal tenderness is typically over 'McBurney’s point', which lies two-thirds of the way along a line drawn from the umbilicus to the anterior superior iliac spine.
    • Children may present with right lower quadrant pain on coughing or hopping.
  • Abdominal distension, guarding (muscular rigidity), and rebound tenderness or percussion tenderness may suggest peritonitis. Absent bowel sounds may indicate ileus or peritonitis associated with perforation.
  • A palpable abdominal mass may suggest an appendix mass or abscess.
  • Consider testing for peritoneal signs specific for acute appendicitis:
    • Rovsing's sign — palpation of the left lower quadrant increases the pain felt in the right lower quadrant.
    • Psoas sign — passive extension of the right thigh with the person in the left lateral position elicits pain in the right lower quadrant.
    • Obturator sign — passive internal rotation of the flexed right thigh elicits pain in the right lower quadrant.
  • Consider performing a groin and scrotal examination, where appropriate, to exclude an alternative cause, such as incarcerated hernia or testicular torsion.
  • Consider performing a pelvic examination, where appropriate, to exclude an alternative gynaecological cause for symptoms.
  • Note: do not routinely perform a rectal examination to confirm the diagnosis in primary care.
• Be aware of possible atypical presentations of acute appendicitis.
  • Children — infants and young children may present with non-specific abdominal pain and anorexia, and may appear withdrawn.
  • Older age — there may be minimal pain or fever; may present with acute confusion or shock.
  • Pregnancy — there may be displacement of the appendix by the gravid uterus. In the later stages of pregnancy, may present with right upper quadrant or right flank pain. Nausea and vomiting may be mistaken for pregnancy-related symptoms. See the CKS topic on Nausea/vomiting in pregnancy for more information.
  • The anatomical position of the appendix can vary considerably in non-pregnant people:
    • A retrocaecal/retrocolic appendix may present with right loin pain and tenderness, and a positive psoas test. Muscular rigidity and tenderness to deep palpation are often absent because of protection from the overlying caecum.
    • A pre-ileal and post-ileal appendix may present with vomiting and diarrhoea (due to irritation of the distal ileum).
    • A subcaecal and pelvic appendix may present with suprapubic pain and urinary frequency; diarrhoea and tenesmus may be present owing to rectal irritation; abdominal tenderness may be lacking, but rectal or vaginal tenderness may be present on the right side; microscopic haematuria and leucocytes may be present on urine dipstick testing.
    • A long appendix with tip inflammation in the left lower quadrant may cause pain in that region.
• Consider the need for additional investigations to exclude an alternative cause, depending on clinical judgement.
  • Full blood count — neutrophil-predominant leucocytosis is present in 80–90% of people with appendicitis.
  • C-reactive protein (CRP) — raised levels may be present, but normal levels do not exclude a diagnosis of appendicitis.
    • Be aware that the combination of a white blood cell count over 10,000/microlitre or neutrophilia over 75%, with a raised CRP (over 7 mg/L), may be highly suggestive of acute appendicitis.
  • Urine dipstick test — to help exclude a urinary tract infection (UTI).
    • Be aware that as the appendix often lies in close proximity to the urinary tract, 40% of people with acute appendicitis may have leucocytes in their urine. See the CKS topics on Urinary tract infection - children, Urinary tract infection (lower) - men, and Urinary tract infection (lower) - women for more information.
  • Pregnancy test — to exclude ectopic pregnancy and other pregnancy-related conditions. See the CKS topic on Ectopic pregnancy for more information.

What else might it be?

Other conditions that may present similarly to acute appendicitis include:

• Gastrointestinal
  • Gastroenteritis. See the CKS topic on Gastroenteritis for more information.
  • Intestinal obstruction (may present with constipation, abdominal distension, abdominal pain, and vomiting).
  • Incarcerated inguinal hernia (may present with a tender groin mass).
  • Intussusception (may present with right lower quadrant tenderness, a sausage-shaped mass in the abdomen, and redcurrant jelly stool).
  • Malrotation of the midgut (may present with bilious vomiting, abdominal pain, diarrhoea, and bloody stools).
  • Meckel diverticulum (in children, may present with gastrointestinal bleeding, diverticulitis, bowel obstruction, peritonitis, intussusception, or volvulus).
  • Biliary colic and acute cholecystitis. See the CKS topic on Cholecystitis - acute for more information.
  • Perforated peptic ulcer. See the CKS topic on Dyspepsia - proven peptic ulcer for more information.
  • Diverticulitis. See the CKS topic on Diverticular disease for more information.
  • Pancreatitis. See the CKS topic on Pancreatitis - acute for more information.
  • Inflammatory bowel disease (particularly ileocaecal Crohn's disease, terminal ileitis). See the CKS topic on Crohn's disease for more information.
  • Irritable bowel syndrome. See the CKS topic on Irritable bowel syndrome for more information.
  • Constipation. See the CKS topics on Constipation and Constipation in children for more information.
  • Primary peritonitis (most presentations involve abrupt abdominal pain, fever, distension, and rebound tenderness, there may be a history of advanced cirrhosis or nephrosis).
  • Foreign body ingestion (such as magnets or button batteries).
  • Carcinoma of the appendix. Primary appendiceal neoplasms are rare; found in approximately 1% of pathology specimens.  
• Urological
  • Right ureteric colic. See the CKS topic on Renal or ureteric colic - acute for more information.
  • Right pyelonephritis. See the CKS topic on Pyelonephritis - acute for more information.
  • Urinary tract infection. See the CKS topics on Urinary tract infection - children, Urinary tract infection (lower) - men, and Urinary tract infection (lower) - women for more information.
  • Urinary retention.
  • Testicular torsion (may present with abdominal pain with nausea or vomiting in boys). See the CKS topic on Scrotal pain and swelling for more information.
• Gynaecological
  • Ectopic pregnancy. See the CKS topic on Ectopic pregnancy for more information.
  • Ruptured ovarian cyst or ovarian torsion (may present with intermittent, non-radiating unilateral lower abdominal pain).
  • Ruptured ovarian follicle causing mid-cycle pain ('Mittelschmerz').
  • Pelvic inflammatory disease, salpingitis, or tubo-ovarian abscess. See the CKS topic on Pelvic inflammatory disease for more information.
  • Endometriosis or adenomyosis. See the CKS topic on Endometriosis for more information.
  • Fibroids (may present with heavy menstrual bleeding and abdominal pain). See the CKS topic on Menorrhagia for more information.
  • Dysmenorrhoea. See the CKS topic on Dysmenorrhoea for more information.
• Other
  • Pneumonia (basal pneumonia may present with referred abdominal pain). See the CKS topics on Chest infections - adult and Cough - acute with chest signs in children for more information.
  • Radicular back pain or lumbar discitis. See the CKS topic on Sciatica (lumbar radiculopathy) for more information.
  • Non-specific abdominal pain (may present in children with poorly localized non-specific symptoms, periumbilical pain of variable intensity, not associated with peritonism, and which tends to self-resolve).
  • Mesenteric adenitis (enlarged mesenteric lymph nodes caused by viral infection — pain in the abdomen is usually diffuse with tenderness not localised to the right lower quadrant, and generalized lymphadenopathy may also be noted).
  • Abdominal wall abscess or haematoma.
  • Diabetic ketoacidosis. See the CKS topic on Diabetes - type 1 for more information.
  • Shingles (pre-herpetic pain on the right 10th and 11th dorsal nerves). See the CKS topic on Shingles for more information.
  • Acute porphyria (rare).

Scenario: Managing suspected appendicitis

From age 1 month onwards.

Search strategy

Scope of search

A literature search was conducted for guidelines and systematic reviews on primary care management of appendicitis.

Search dates

June 2020 - February 2025

Key search terms

The terms listed below are the core search terms that were used for EBSCOhost MEDLINE (searched 10th June 2020). These were combined with filters to identify guidelines, systematic reviews and primary care relevant literature in EBSCOhost MEDLINE. The strategy was adapted for The Cochrane Library databases. 

S3    S1 OR S2 
S2    AB appendicitis OR TI appendicitis 
S1    (MH "Appendicitis") 

Sources of guidelines

• National Institute for Health and Care Excellence (NICE)
• Scottish Intercollegiate Guidelines Network (SIGN)
• Royal College of Physicians
• Royal College of General Practitioners
• Royal College of Nursing
• NICE Evidence
• World Health Organization
• Guidelines International Network
• TRIP database
• Agency for Healthcare Research and Quality
• Institute for Clinical Systems Improvement
• National Health and Medical Research Council (Australia)
• Royal Australian College of General Practitioners
• British Columbia Medical Association
• Canadian Medical Association
• Alberta Medical Association
• Michigan Quality Improvement Consortium
• Singapore Ministry of Health
• National Resource for Infection Control
• RefHELP NHS Lothian Referral Guidelines
• Medline (with guideline filter)
• Driver and Vehicle Licensing Agency
• NHS Health at Work (occupational health practice)

Sources of systematic reviews and meta-analyses

• The Cochrane Library:
  • Systematic reviews
  • Protocols
  • Database of Abstracts of Reviews of Effects
• Medline (with systematic review filter)
• EMBASE (with systematic review filter)

Sources of health technology assessments and economic appraisals

• NIHR Health Technology Assessment programme
• The Cochrane Library:
  • NHS Economic Evaluations
  • Health Technology Assessments
• Canadian Agency for Drugs and Technologies in Health
• International Network of Agencies for Health Technology Assessment

Sources of randomized controlled trials

• The Cochrane Library:
  • Central Register of Controlled Trials
• Medline (with randomized controlled trial filter)
• EMBASE (with randomized controlled trial filter)

Sources of evidence based reviews and evidence summaries

• Bandolier
• Drug and Therapeutics Bulletin
• TRIP database
• Central Services Agency COMPASS Therapeutic Notes

Sources of national policy

• Department of Health
• Health Management Information Consortium (HMIC)

Patient experiences

• Healthtalk
• BMJ - Patient Journeys

Sources of medicines information

The following sources are used by CKS pharmacists and are not necessarily searched by CKS information specialists for all topics. Some of these resources are not freely available and require subscriptions to access content.

• British National Formulary (BNF)
• electronic Medicines Compendium (eMC)
• European Medicines Agency (EMEA)
• LactMed
• Medicines and Healthcare products Regulatory Agency (MHRA)
• REPROTOX
• Scottish Medicines Consortium
• Stockley's Drug Interactions
• TERIS
• TOXBASE
• Micromedex
• UK Medicines Information

Stakeholder engagement

Our policy

The external review process is an essential part of CKS topic development. Consultation with a wide range of stakeholders provides quality assurance of the topic in terms of:

• Clinical accuracy.
• Consistency with other providers of clinical knowledge for primary care.
• Accuracy of implementation of national guidance (in particular NICE guidelines).
• Usability.

Principles of the consultation process

• The process is inclusive and any individual may participate.
• To participate, an individual must declare whether they have any competing interests or not. If they do not declare whether or not they have competing interests, their comments will not be considered.
• Comments received after the deadline will be considered, but they may not be acted upon before the clinical topic is issued onto the website.
• Comments are accepted in any format that is convenient to the reviewer, although an electronic format is encouraged.
• External reviewers are not paid for commenting on the draft topics.
• Discussion with an individual or an organization about the CKS response to their comments is only undertaken in exceptional circumstances (at the discretion of the Clinical Editor or Editorial Steering Group).
• All reviewers are thanked and offered a letter acknowledging their contribution for the purposes of appraisal/revalidation.
• All reviewers are invited to be acknowledged on the website. All reviewers are given the opportunity to feedback about the external review process, enabling improvements to be made where appropriate.

Stakeholders

• Key stakeholders identified by the CKS team are invited to comment on draft CKS topics. Individuals and organizations can also register an interest to feedback on a specific topic, or topics in a particular clinical area, through the Getting involved section of the Clarity Informatics website.
• Stakeholders identified from the following groups are invited to review draft topics:
  • Experts in the topic area.
  • Professional organizations and societies (for example, Royal Colleges).
  • Patient organizations, Clarity has established close links with groups such as Age UK and the Alzheimer’s Society specifically for their input into new topic development, review of current topic content and advice on relevant areas of expert knowledge.
  • Guideline development groups where the topic is an implementation of a guideline.
  • The British National Formulary team.
  • The editorial team that develop MeReC Publications.
• Reviewers are provided with clear instructions about what to review, what comments are particularly helpful, how to submit comments, and declaring interests.

Patient engagement

Clarity Informatics has enlisted the support and involvement of patients and lay persons at all stages in the process of creating the content which include:

• Topic selection
• Scoping of topic
• Selection of clinical scenarios
• First draft internal review
• Second draft internal review
• External review
• Final draft and pre-publication

Our lay and patient involvement includes membership on the editorial steering group, contacting expert patient groups, organizations and individuals.

Evidence exclusion criteria

Our policy

Scoping a literature search, and reviewing the evidence for CKS is a methodical and systematic process that is carried out by the lead clinical author for each topic. Relevant evidence is gathered in order that the clinical author can make fully informed decisions and recommendations. It is important to note that some evidence may be excluded for a variety of reasons. These reasons may be applied across all CKS topics or may be specific to a given topic.

Studies identified during literature searches are reviewed to identify the most appropriate information to author a CKS topic, ensuring any recommendations are based on the best evidence. We use the principles of the GRADE and PICOT approaches to assess the quality of published research. We use the principles of AGREE II to assess the quality of published guidelines.

Standard exclusions for scoping literature:

• Animal studies
• Original research is not written in English

Possible exclusions for reviewed literature:

• Sample size too small or study underpowered
• Bias evident or promotional literature
• Population not relevant
• Intervention/treatment not relevant
• Outcomes not relevant
• Outcomes have no clear evidence of clinical effectiveness
• Setting not relevant
• Not relevant to UK
• Incorrect study type
• Review article
• Duplicate reference

Organizational, behavioural and financial barriers

Our policy

The CKS literature searches take into consideration the following concepts, which are discussed at the initial scoping of the topic.

• Feasibility
  • Studies are selected depending on whether the intervention under investigation is available in the NHS and can be practically and safely undertaken in primary care.
• Organizational and Financial Impact Analysis
• Studies are selected and evaluated on whether the intervention under investigations may have an impact on local clinical service provision or national impact on cost for the NHS. The principles of clinical budget impact analysis are adhered to, evaluated and recorded by the author. The following factors are considered when making this assessment and analysis.
  • Eligible population
  • Current interventions
  • Likely uptake of new intervention or recommendation
  • Cost of the current or new intervention mix
  • Impact on other costs
  • Condition-related costs
  • In-direct costs and service impacts
  • Time dependencies
• Cost-effectiveness or cost-benefit analysis studies are identified where available. 

We also evaluate and include evidence from NICE accredited sources which provide economic evaluations of recommendations, such as NICE guidelines. When a recommended action may not be possible because of resource constraints, this is explicitly indicated to healthcare professionals by the wording of the CKS recommendation.

Declarations of interest

Our policy

Clarity Informatics requests that all those involved in the writing and reviewing of topics, and those involved in the external review process to declare any competing interests. Signed copies are securely held by Clarity Informatics and are available on request with the permission of the individual. A copy of the declaration of interest form which participants are asked to complete annually is also available on request. A brief outline of the declarations of interest policy is described here and full details of the policy is available on the Clarity Informatics website. Declarations of interests of the authors are not routinely published, however competing interests of all those involved in the topic update or development are listed below. Competing interests include:

• Personal financial interests
• Personal family interest
• Personal non-financial interest
• Non-personal financial gain or benefit

Although particular attention is given to interests that could result in financial gains or losses for the individual, competing interests may also arise from academic competition or for political, personal, religious, and reputational reasons. An individual is not obliged to seek out knowledge of work done for, or on behalf of, the healthcare industry within the departments for which they are responsible if they would not normally expect to be informed.

Who should declare competing interests?

Any individual (or organization) involved in developing, reviewing, or commenting on clinical content, particularly the recommendations should declare competing interests. This includes the authoring team members, expert advisers, external reviewers of draft topics, individuals providing feedback on published topics, and Editorial Steering Group members. Declarations of interest are completed annually for authoring team and editorial steering group members, and are completed at the start of the topic update and development process for external stakeholders.

Competing interests declared for this topic:

None.