Does a decision aid help physicians to detect chronic obstructive pulmonary disease?

Broekhuizen, Berna D L; Sachs, A. P. E.; Janssen, Kristel J.M.; Geersing, Geert‐Jan; Moons, Karel G.M.; Hoes, Arno W.; Verheij, Theo

doi:10.3399/bjgp11x601398

Cited by 6 publications

(5 citation statements)

References 24 publications

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“…The effect of a CPR when used in conjunction with clinical judgment can only be fully tested in a study design in which participants are assigned (ideally randomly) to apply or receive clinical judgment alone or clinical judgment with access to a CPR. However, studies of diagnostic accuracy or incremental value [ 41 , 42 ] provide a useful and less costly interim step in the evaluation of CPRs prior to a randomised controlled trial and can guide future research.…”

Section: Discussionmentioning

confidence: 99%

A Systematic Review of Studies Comparing Diagnostic Clinical Prediction Rules with Clinical Judgment

2015

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BackgroundDiagnostic clinical prediction rules (CPRs) are developed to improve diagnosis or decrease diagnostic testing. Whether, and in what situations diagnostic CPRs improve upon clinical judgment is unclear.Methods and FindingsWe searched MEDLINE, Embase and CINAHL, with supplementary citation and reference checking for studies comparing CPRs and clinical judgment against a current objective reference standard. We report 1) the proportion of study participants classified as not having disease who hence may avoid further testing and or treatment and 2) the proportion, among those classified as not having disease, who do (missed diagnoses) by both approaches. 31 studies of 13 medical conditions were included, with 46 comparisons between CPRs and clinical judgment. In 2 comparisons (4%), CPRs reduced the proportion of missed diagnoses, but this was offset by classifying a larger proportion of study participants as having disease (more false positives). In 36 comparisons (78%) the proportion of diagnoses missed by CPRs and clinical judgment was similar, and in 9 of these, the CPRs classified a larger proportion of participants as not having disease (fewer false positives). In 8 comparisons (17%) the proportion of diagnoses missed by the CPRs was greater. This was offset by classifying a smaller proportion of participants as having the disease (fewer false positives) in 2 comparisons. There were no comparisons where the CPR missed a smaller proportion of diagnoses than clinical judgment and classified more participants as not having the disease. The design of the included studies allows evaluation of CPRs when their results are applied independently of clinical judgment. The performance of CPRs, when implemented by clinicians as a support to their judgment may be different.ConclusionsIn the limited studies to date, CPRs are rarely superior to clinical judgment and there is generally a trade-off between the proportion classified as not having disease and the proportion of missed diagnoses. Differences between the two methods of judgment are likely the result of different diagnostic thresholds for positivity. Which is the preferred judgment method for a particular clinical condition depends on the relative benefits and harms of true positive and false positive diagnoses.

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Section: Discussionmentioning

confidence: 99%

A Systematic Review of Studies Comparing Diagnostic Clinical Prediction Rules with Clinical Judgment

2015

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“…We calculated negative and positive predictive value, sensitivity, and specificity for these three risk groups (taking one risk group compared with the other two combined), as well as and positive and negative likelihood ratios. The cut-off levels of the three risk groups were based on clinical judgment of the authors and assessment of acceptability of false negative results in other diagnostic studies in primary care 3839 40 41 We carried out a sensitivity analysis around these thresholds using low thresholds of 1% and 2% and high thresholds of 15% and 25%.…”

Section: Methodsmentioning

confidence: 99%

Use of serum C reactive protein and procalcitonin concentrations in addition to symptoms and signs to predict pneumonia in patients presenting to primary care with acute cough: diagnostic study

Vugt

Broekhuizen

Lammens

et al. 2013

BMJ

191

215

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Objectives To quantify the diagnostic accuracy of selected inflammatory markers in addition to symptoms and signs for predicting pneumonia and to derive a diagnostic tool.Design Diagnostic study performed between 2007 and 2010. Participants had their history taken, underwent physical examination and measurement of C reactive protein (CRP) and procalcitonin in venous blood on the day they first consulted, and underwent chest radiography within seven days. Setting Primary care centres in 12 European countries.Participants Adults presenting with acute cough.Main outcome measures Pneumonia as determined by radiologists, who were blind to all other information when they judged chest radiographs. ResultsOf 3106 eligible patients, 286 were excluded because of missing or inadequate chest radiographs, leaving 2820 patients (mean age 50, 40% men) of whom 140 (5%) had pneumonia. Re-assessment of a subset of 1675 chest radiographs showed agreement in 94% (κ 0.45, 95% confidence interval 0.36 to 0.54). Six published "symptoms and signs models" varied in their discrimination (area under receiver operating characteristics curve (ROC) ranged from 0.55 (95% confidence interval 0.50 to 0.61) to 0.71 (0.66 to 0.76)). The optimal combination of clinical prediction items derived from our patients included absence of runny nose and presence of breathlessness, crackles and diminished breath sounds on auscultation, tachycardia, and fever, with an ROC area of 0.70 (0.65 to 0.75). Addition of CRP at the optimal cut off of >30 mg/L increased the ROC area to 0.77 (0.73 to 0.81) and improved the diagnostic classification (net reclassification improvement 28%). In the 1556 patients classified according to symptoms, signs, and CRP >30 mg/L as "low risk" (<2.5%) for pneumonia, the prevalence of pneumonia was 2%. In the 132 patients classified as "high risk" (>20%), the prevalence of pneumonia was 31%. The positive likelihood ratio of low, intermediate, and high risk for pneumonia was 0.4, 1.2, and 8.6 respectively. Measurement of procalcitonin added no relevant additional diagnostic information. A simplified diagnostic score based on symptoms, signs, and CRP >30 mg/L resulted in proportions of pneumonia of 0.7%, 3.8%, and 18.2% in the low, intermediate, and high risk group respectively.Conclusions A clinical rule based on symptoms and signs to predict pneumonia in patients presenting to primary care with acute cough performed best in patients with mild or severe clinical presentation. RESEARCHAddition of CRP concentration at the optimal cut off of >30 mg/L improved diagnostic information, but measurement of procalcitonin concentration did not add clinically relevant information in this group. IntroductionDiagnosis of pneumonia in adults presenting with signs of lower respiratory tract infection in primary care is important because pneumonia requires specific treatment and follow-up, whereas for acute bronchitis expectant management is usually appropriate.1 Nonetheless, accurate diagnosis of pneumonia in primary care is difficult as it...

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“…The sensitivity and specificity of clinicians’ predictions or decisions are generally measured under usual practice, and compared to the sensitivity and specificity of the CPR predictions or decisions when applied to the same patients [226, 227]. Some studies have used clinical vignettes [228] while others have used multivariable logistic models to assess the added value of a CPR over and above clinical judgement alone [229]. If it can be demonstrated that the performance of a CPR is superior to unaided clinician judgement, this may aid clinicians’ acceptance and use of the CPR [32].…”

Section: Stages In the Development Of Clinical Prediction Rulesmentioning

confidence: 99%

Methodological standards for the development and evaluation of clinical prediction rules: a review of the literature

et al. 2019

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Clinical prediction rules (CPRs) that predict the absolute risk of a clinical condition or future outcome for individual patients are abundant in the medical literature; however, systematic reviews have demonstrated shortcomings in the methodological quality and reporting of prediction studies. To maximise the potential and clinical usefulness of CPRs, they must be rigorously developed and validated, and their impact on clinical practice and patient outcomes must be evaluated. This review aims to present a comprehensive overview of the stages involved in the development, validation and evaluation of CPRs, and to describe in detail the methodological standards required at each stage, illustrated with examples where appropriate. Important features of the study design, statistical analysis, modelling strategy, data collection, performance assessment, CPR presentation and reporting are discussed, in addition to other, often overlooked aspects such as the acceptability, cost-effectiveness and longer-term implementation of CPRs, and their comparison with clinical judgement. Although the development and evaluation of a robust, clinically useful CPR is anything but straightforward, adherence to the plethora of methodological standards, recommendations and frameworks at each stage will assist in the development of a rigorous CPR that has the potential to contribute usefully to clinical practice and decision-making and have a positive impact on patient care.

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Does a decision aid help physicians to detect chronic obstructive pulmonary disease?

Cited by 6 publications

References 24 publications

A Systematic Review of Studies Comparing Diagnostic Clinical Prediction Rules with Clinical Judgment

A Systematic Review of Studies Comparing Diagnostic Clinical Prediction Rules with Clinical Judgment

Use of serum C reactive protein and procalcitonin concentrations in addition to symptoms and signs to predict pneumonia in patients presenting to primary care with acute cough: diagnostic study

Methodological standards for the development and evaluation of clinical prediction rules: a review of the literature

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