Structured Clinical Decision Aids Are Seldom Compared With Subjective Physician Judgment, and Are Seldom Superior

Schriger, David L.; Elder, Joshua W.; Cooper, Richelle J.

doi:10.1016/j.annemergmed.2016.12.004

Cited by 72 publications

(60 citation statements)

References 17 publications

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“…The purpose of any scoring system or clinical decision rule is to augment and improve clinical judgment, not to replace it. [57][58][59][60] We were unable to identify any studies of such actual combined application. Any apparent predictive value of the Mallampati score may have already been captured in the standard general airway assessment.…”

Section: Discussionmentioning

confidence: 99%

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Is the Mallampati Score Useful for Emergency Department Airway Management or Procedural Sedation?

Green

Roback

2019

Annals of Emergency Medicine

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We review the literature in regard to the accuracy, reliability, and feasibility of the Mallampati score as might be pertinent and applicable to emergency department (ED) airway management and procedural sedation. This 4-level pictorial tool was devised to predict difficult preoperative laryngoscopy and intubation, but is now also widely recommended as a routine screening element before procedural sedation. The literature evidence demonstrates that the Mallampati score is inadequately sensitive for the identification of difficult laryngoscopy, difficult intubation, and difficult bag-valve-mask ventilation, with likelihood ratios indicating a small and clinically insignificant effect on outcome prediction. Although it is important to anticipate that patients may have a difficult airway, there is no specific evidence that the Mallampati score augments or improves the baseline clinical judgment of a standard airway evaluation. It generates numerous false-positive warnings for each correct prediction of a difficult airway. The Mallampati score is not reliably assessed because independent observers commonly grade it differently. It cannot be evaluated in many young children and in patients who cannot cooperate because of their underlying medical condition. The Mallampati score lacks the accuracy, reliability, and feasibility required to supplement a standard airway evaluation before ED airway management or procedural sedation. [

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Section: Discussionmentioning

confidence: 99%

“…Any apparent predictive value of the Mallampati score may have already been captured in the standard general airway assessment. [57][58][59][60] There is thus no literature evidence to directly support the contention that Mallampati score augments or improves the standard clinical judgment of the general airway evaluation alone.…”

Section: Discussionmentioning

confidence: 99%

Is the Mallampati Score Useful for Emergency Department Airway Management or Procedural Sedation?

Green

Roback

2019

Annals of Emergency Medicine

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“…Importantly, none of the included studies compared accuracy of the HEART score to clinician gestalt. ED clinical decision instruments are rarely compared to clinician gestalt and are often not superior . While the performance of the HEART score among low‐risk patients is reassuring, it is unclear whether the score identifies less patients as “low risk” compared to clinician gestalt and may ultimately lead to further downstream testing.…”

Section: Limitationsmentioning

confidence: 99%

Prognostic Accuracy of the HEART Score for Prediction of Major Adverse Cardiac Events in Patients Presenting With Chest Pain: A Systematic Review and Meta‐analysis

Fernando

Tran

Cheng

et al. 2018

Academic Emergency Medicine

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Objective: The HEART score has been proposed for emergency department (ED) prediction of major adverse cardiac events (MACE). We sought to summarize all studies assessing the prognostic accuracy of the HEART score for prediction of MACE in adult ED patients presenting with chest pain.Methods: We searched MEDLINE, PubMed, EMBASE, Scopus, Web of Science, and the Cochrane Database of Systematic Reviews from inception through May 2018 and included studies using the HEART score for the prediction of short-term MACE in adult patients presenting to the ED with chest pain. The main outcome was short-term (i.e., 30-day or 6-week) incidence of MACE. We secondarily evaluated the prognostic accuracy of the HEART score for prediction of mortality and myocardial infarction (MI). Where available, accuracy of the Thrombolysis in Myocardial Infarction (TIMI) score was determined. Results:We included 30 studies (n = 44,202) in analysis. A HEART score above the low-risk threshold (≥4) had a sensitivity of 95.9% (95% confidence interval [CI] = 93.3%-97.5%) and specificity of 44.6% (95% CI = 38.8%-50.5%) for MACE. A high-risk HEART score (≥7) had a sensitivity of 39.5% (95% CI = 31.6%-48.1%) and specificity of 95.0% (95% CI = 92.6%-96.6%) for MACE, whereas a TIMI score above the low-risk threshold (≥2) had a sensitivity of 87.8% (95% CI = 80.2%-92.8%) and specificity of 48.1% (95% CI = 38.9%-57.5%) for MACE. A high-risk TIMI score (≥6) was 2.8% sensitive (95% CI = 0.8%-9.6%), but 99.6% (95% CI = 98.5%-99.9%) specific for MACE. A HEART score ≥ 4 had a sensitivity of 95.0% (95% CI = 87.2%-98.2%) for prediction of mortality and 97.5% (95% CI = 93.7%-99.0%) for prediction of MI.

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“…The goal of this investigation is to "determine how often studies that evaluate the performance of an aid for decisionmaking.compare the aid's performance to independent unaided physician judgment." 1 A. What was the primary outcome measure?…”

Section: Discussion Pointsmentioning

confidence: 99%

Clinical Decision Aids or Clinician Gestalt? Hard to Know Which Is Better

Williams

Kaji

2018

Annals of Emergency Medicine

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Structured Clinical Decision Aids Are Seldom Compared With Subjective Physician Judgment, and Are Seldom Superior

Cited by 72 publications

References 17 publications

Is the Mallampati Score Useful for Emergency Department Airway Management or Procedural Sedation?

Is the Mallampati Score Useful for Emergency Department Airway Management or Procedural Sedation?

Prognostic Accuracy of the HEART Score for Prediction of Major Adverse Cardiac Events in Patients Presenting With Chest Pain: A Systematic Review and Meta‐analysis

Clinical Decision Aids or Clinician Gestalt? Hard to Know Which Is Better

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