The most ideal design would be a clustered center randomized trial. In such a case half of the hospitals will be asked to use the LAPP score and the other half should assess the appendix the conventional way. The investigators feel that it is not feasible, as they already presented the LAPP score at the national congress for surgeons. In addition, after publication of the results of the LAPP study surgeons might already start to use the LAPP score or at least will evaluate the appendix differently than before. [3]