Diagnostic strategy
Caroline J Rodgers, Richard Harrington in Helping Hands: An Introduction to Diagnostic Strategy and Clinical Reasoning, 2019
Clinical prediction rules can be very helpful tools when used alongside other diagnostic strategies to improve the accuracy of diagnosis and aid decisions regarding further investigation and treatment. Keogh et al. recently created a register of clinical prediction rules used in primary care and found 434 rules in the literature.11 Of these, just over half had been validated, and a very small percentage had been assessed in terms of their clinical impact.11 Hence it is important when applying a clinical prediction rule in practice to understand the evidence base for it and thus have an appreciation of its reliability. The development of an international web-based register of clinical prediction rules will go a long way towards helping clinicians make decisions on which rules to use.11
Prognosis: Studies of disease course and outcomes
Milos Jenicek in Foundations of Evidence-Based Medicine, 2019
Clinical prediction rules (syn. clinical decision rules) are tools that assist practitioners by estimating the probability either of a diagnostic outcome or of a prognostic outcome.78 A clinical prediction rule is defined as a ‘decision-making tool for clinicians that includes three or more variables obtained from the history, physical examination, or simple diagnostic tests and that either provided the probability of an outcome or suggested a diagnostic or therapeutic course of action’.79 Clinical prediction tools belong therefore to both diagnosis and prognosis.80 For example the Ottawa Ankle Rules81 is a prediction tool that should help clinicians decide if a patient with an ankle injury evaluated in an emergency department needs ankle x-ray series or not: ‘An ankle x-ray series is required only if there is any pain in the malleolar zone and any of these findings:Bone tenderness at the posterior edge or tip of the lateral malleolus,orBone tenderness at the posterior edge or tip of medial malleolus,orInability to bear weight both immediately and in emergency department’.80,81
Cardiovascular medicine
Shibley Rahman, Avinash Sharma in A Complete MRCP(UK) Parts 1 and 2 Written Examination Revision Guide, 2018
The CHADS2 score is probably the best validated clinical prediction rule for determining the risk of stroke and who should be anticoagulated. It assigns points (0–6) depending on the presence or absence of co-morbidities. To compensate for the increased risk of stroke, anticoagulation may be necessary. However, with warfarin, if a patient has a yearly risk of stroke that is less than 2%, then the risks associated with taking warfarin outweigh the risk of getting a stroke from atrial fibrillation.
Comparison of lower-dose versus higher-dose intravenous naloxone on time to recurrence of opioid toxicity in the emergency department
Published in Clinical Toxicology, 2019
Felicia Wong, Christopher J. Edwards, Daniel H. Jarrell, Asad E. Patanwala
A few studies have reported the recurrence of toxicity after opioid overdose and need for re-dosing of naloxone [8–11]. Christenson etal. developed a clinical prediction rule derived from 573 patients [8]. The authors identified patient characteristics that would enable safe discharge from the ED one hour after naloxone administration. The prediction rule included the ability to mobilize as usual, oxygen saturation on room air >92%, respiratory rate >10 to <20 breaths per minute, temperature >35 to <37.5°C, heart rate >50 to <100 beats per minute, and the Glasgow Coma Scale score of 15. Although this rule has not been validated, it suggests that only a subset of patients will require further care and are at risk for recurrence of toxicity. Our study primarily pertains to those patients who will likely require on-going care.
Predictors for mortality due to acute exacerbation of COPD in primary care: Derivation of a clinical prediction rule in a multicentre cohort study
Published in European Journal of General Practice, 2021
César Alameda, Ángel Carlos Matía, Verónica Casado
As expressed in the GOLD guidelines, ‘prevention, early detection, and prompt treatment of exacerbations are vital to reduce the burden of COPD.’ Although some predictive models have been published, they were derived and validated in the hospital setting. Almost all these models include variables that cannot be assessed in primary care (PC) [10–16]. We hypothesised that past medical history, symptoms, and signs in a person who suffers an acute exacerbation of COPD (AECOPD) and is treated in PC allow predicting his or her death in the short term. The objective of this study was to derive a clinical prediction rule (CPR) that contained these predictors and supported making the best decisions in the care provided to these patients.
Added value of CRP to clinical features when assessing appendicitis in children
Published in European Journal of General Practice, 2022
Guus C. G. H. Blok, Eelke D. Nikkels, Johan van der Lei, Marjolein Y. Berger, Gea A. Holtman
Given that CRP added value to routine assessment, we must now consider how to include it in a clinical prediction rule. It is also unknown if testing with or without a clinical prediction rule affects GPs decisions and patient outcomes. Therefore, before recommending CRP in primary care, the impact of its use on patient outcomes should be evaluated in a randomised controlled trial.
