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Brasseur E, Gilbert A, Donneau AF, Monseur J, Ghuysen A, D’Orio V. Reliability and validity of an original nurse telephone triage tool for out-of-hours primary care calls: the SALOMON algorithm. Acta Clin Belg 2022; 77:640-646. [PMID: 34081571 DOI: 10.1080/17843286.2021.1936353] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVES Due to the persistent primary care physicians shortage and the substantial increase in their workload, the organization of primary care calls during out-of-hours periods has become an everyday challenge. The SALOMON algorithm is an original nurse telephone triage tool allowing to dispatch patients to the best level of care according to their conditions. This study evaluated its reliability and criterion validity in rea-life settings. METHODS In this 5-year study, out-of-hours primary care calls were dispatched into four categories: Emergency Medical Services Intervention (EMSI), Emergency Department referred Consultation (EDRC), Primary Care Physician Home visit (PCPH), and Primary Care Physician Delayed visit (PCPD). We included data of patients' triage category, resources, and destination. Patients included into the primary care cohort were classified undertriaged if they had to be redirected to an emergency department (ED). Patients from the ED cohort were considered overtriaged if they did not require at least three diagnostic resources, one emergency-specific treatment or any hospitalization. In the ED cohort, only patients from the University Hospitals were considered. RESULTS 10,207 calls were triaged using the SALOMON tool: 19.2% were classified as EMSI, 15.8% as EDRC, 62.8% as PCPH, and 2.2% as PCPD. The triage was appropriate for 85.5% of the calls with a 14.5% overtriage rate. In the PCPD/PCPH cohort, 96.9% of the calls were accurately triaged and 3.1% were undertriaged. SALOMON sensitivity and specificity reached 76.6% and 98.3%, respectively. CONCLUSION SALOMON algorithm is a valid triage tool that has the potential to improve the organization of out-of-hours primary care work.
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Affiliation(s)
- Edmond Brasseur
- Emergency Department, University Hospital Center of Liège, Liège, Belgium
| | - Allison Gilbert
- Emergency Department, University Hospital Center of Liège, Liège, Belgium
| | - Anne-Françoise Donneau
- Biostatistics Unit, University of Liège, Liège, Belgium
- Public Health Department, University of Liège, Liège, Belgium
| | - Justine Monseur
- Biostatistics Unit, University of Liège, Liège, Belgium
- Public Health Department, University of Liège, Liège, Belgium
| | - Alexandre Ghuysen
- Emergency Department, University Hospital Center of Liège, Liège, Belgium
- Public Health Department, University of Liège, Liège, Belgium
| | - Vincent D’Orio
- Emergency Department, University Hospital Center of Liège, Liège, Belgium
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Walsh T, Macey R, Kerr AR, Lingen MW, Ogden GR, Warnakulasuriya S. Diagnostic tests for oral cancer and potentially malignant disorders in patients presenting with clinically evident lesions. Cochrane Database Syst Rev 2021; 7:CD010276. [PMID: 34282854 PMCID: PMC8407012 DOI: 10.1002/14651858.cd010276.pub3] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Squamous cell carcinoma is the most common form of malignancy of the oral cavity, and is often proceeded by oral potentially malignant disorders (OPMD). Early detection of oral cavity squamous cell carcinoma (oral cancer) can improve survival rates. The current diagnostic standard of surgical biopsy with histology is painful for patients and involves a delay in order to process the tissue and render a histological diagnosis; other diagnostic tests are available that are less invasive and some are able to provide immediate results. This is an update of a Cochrane Review first published in 2015. OBJECTIVES Primary objective: to estimate the diagnostic accuracy of index tests for the detection of oral cancer and OPMD, in people presenting with clinically evident suspicious and innocuous lesions. SECONDARY OBJECTIVE to estimate the relative accuracy of the different index tests. SEARCH METHODS Cochrane Oral Health's Information Specialist searched the following databases: MEDLINE Ovid (1946 to 20 October 2020), and Embase Ovid (1980 to 20 October 2020). The US National Institutes of Health Ongoing Trials Register (ClinicalTrials.gov) and the World Health Organization International Clinical Trials Registry Platform were also searched for ongoing trials to 20 October 2020. No restrictions were placed on the language or date of publication when searching the electronic databases. We conducted citation searches, and screened reference lists of included studies for additional references. SELECTION CRITERIA We selected studies that reported the diagnostic test accuracy of the following index tests when used as an adjunct to conventional oral examination in detecting OPMD or oral cavity squamous cell carcinoma: vital staining (a dye to stain oral mucosa tissues), oral cytology, light-based detection and oral spectroscopy, blood or saliva analysis (which test for the presence of biomarkers in blood or saliva). DATA COLLECTION AND ANALYSIS Two review authors independently screened titles and abstracts for relevance. Eligibility, data extraction and quality assessment were carried out by at least two authors, independently and in duplicate. Studies were assessed for methodological quality using the Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2). Meta-analysis was used to combine the results of studies for each index test using the bivariate approach to estimate the expected values of sensitivity and specificity. MAIN RESULTS This update included 63 studies (79 datasets) published between 1980 and 2020 evaluating 7942 lesions for the quantitative meta-analysis. These studies evaluated the diagnostic accuracy of conventional oral examination with: vital staining (22 datasets), oral cytology (24 datasets), light-based detection or oral spectroscopy (24 datasets). Nine datasets assessed two combined index tests. There were no eligible diagnostic accuracy studies evaluating blood or salivary sample analysis. Two studies were classed as being at low risk of bias across all domains, and 33 studies were at low concern for applicability across the three domains, where patient selection, the index test, and the reference standard used were generalisable across the population attending secondary care. The summary estimates obtained from the meta-analysis were: - vital staining: sensitivity 0.86 (95% confidence interval (CI) 0.79 to 0.90) specificity 0.68 (95% CI 0.58 to 0.77), 20 studies, sensitivity low-certainty evidence, specificity very low-certainty evidence; - oral cytology: sensitivity 0.90 (95% CI 0.82 to 0.94) specificity 0.94 (95% CI 0.88 to 0.97), 20 studies, sensitivity moderate-certainty evidence, specificity moderate-certainty evidence; - light-based: sensitivity 0.87 (95% CI 0.78 to 0.93) specificity 0.50 (95% CI 0.32 to 0.68), 23 studies, sensitivity low-certainty evidence, specificity very low-certainty evidence; and - combined tests: sensitivity 0.78 (95% CI 0.45 to 0.94) specificity 0.71 (95% CI 0.53 to 0.84), 9 studies, sensitivity very low-certainty evidence, specificity very low-certainty evidence. AUTHORS' CONCLUSIONS At present none of the adjunctive tests can be recommended as a replacement for the currently used standard of a surgical biopsy and histological assessment. Given the relatively high values of the summary estimates of sensitivity and specificity for oral cytology, this would appear to offer the most potential. Combined adjunctive tests involving cytology warrant further investigation. Potentially eligible studies of blood and salivary biomarkers were excluded from the review as they were of a case-control design and therefore ineligible. In the absence of substantial improvement in the tests evaluated in this updated review, further research into biomarkers may be warranted.
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Affiliation(s)
- Tanya Walsh
- Division of Dentistry, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - Richard Macey
- Division of Dentistry, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - Alexander R Kerr
- Department of Oral and Maxillofacial Pathology, Radiology and Medicine, New York University College of Dentistry, New York, USA
| | - Mark W Lingen
- Pritzker School of Medicine, Division of Biological Sciences, Department of Pathology, University of Chicago, Chicago, Illinois, USA
| | - Graham R Ogden
- Division of Oral and Maxillofacial Clinical Sciences, School of Dentistry, University of Dundee, Dundee, UK
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de Virgilio C, Grigorian A, Petrie BA, Arnell TD. Right Lower Quadrant Abdominal Pain. Surgery 2020. [DOI: 10.1007/978-3-030-05387-1_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Minian N, Baliunas D, Noormohamed A, Zawertailo L, Giesbrecht N, Hendershot CS, Le Foll B, Rehm J, Samokhvalov AV, Selby PL. The effect of a clinical decision support system on prompting an intervention for risky alcohol use in a primary care smoking cessation program: a cluster randomized trial. Implement Sci 2019; 14:85. [PMID: 31443663 PMCID: PMC6708174 DOI: 10.1186/s13012-019-0935-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Accepted: 08/15/2019] [Indexed: 01/31/2023] Open
Abstract
Background Clinical decision support systems (CDSSs) may promote practitioner adherence to evidence-based guidelines. This study examined if the addition of a CDSS influenced practitioner delivery of a brief intervention with treatment-seeking smokers who were drinking above recommended alcohol consumption guidelines, compared with practitioners who do not receive a CDSS prompt. Methods This was a cluster randomized controlled trial conducted in primary health care clinics across Ontario, Canada, implementing the Smoking Treatment for Ontario Patients (STOP) smoking cessation program. Clinics randomized to the intervention group received a prompt when a patient reported consuming alcohol above the Canadian Cancer Society (CCS) guidelines; the control group did not receive computer alerts. The primary outcome was an offer of an appropriate educational alcohol resource, an alcohol reduction workbook for patients drinking above the CCS guidelines, and an abstinence workbook to patients scoring above 20 points in the AUDIT screening tool; the secondary outcome was patient acceptance of the resource. The tertiary outcome was patient abstinence from smoking, and alcohol consumption within CCS guidelines, at 6-month follow-up. Results were analyzed using a generalized estimation approach for fitting logistic regression using a population-averaged method. Results Two hundred and twenty-one clinics across Ontario were randomized for this study; 110 to the intervention arm and 111 to the control arm. From the 15,222 patients that enrolled in the smoking cessation program, 15,150 (99.6% of patients) were screened for alcohol use and 5715 patients were identified as drinking above the CCS guidelines. No statistically significant difference between groups was seen in practitioner offer of an educational alcohol resource to appropriate patients (OR = 1.19, 95% CI 0.88–1.64, p = 0.261) or in patient abstinence from smoking and drinking within the CCS guidelines at 6-month follow-up (OR = 0.93, 95% CI 0.71–1.22, p = 0.594). However, a significantly greater proportion of patients in the intervention group accepted the alcohol resource offered to them by their practitioner (OR = 1.48, 95% CI 1.01–2.16, p = 0.045). Conclusion A CDSS may not increase the likelihood of practitioners offering an educational alcohol resource, though it may have influenced patients’ acceptance of the resource. Trial registration This trial is registered with ClinicalTrials.gov, number NCT03108144, registered on April 11, 2017, “retrospectively registered”. Electronic supplementary material The online version of this article (10.1186/s13012-019-0935-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Nadia Minian
- Nicotine Dependence Services, Centre for Addiction and Mental Health, 175 College St, Toronto, ON, M5T1P7, Canada.,Department of Family and Community Medicine, University of Toronto, 500 University Ave, Toronto, ON, M5G 1V7, Canada
| | - Dolly Baliunas
- Nicotine Dependence Services, Centre for Addiction and Mental Health, 175 College St, Toronto, ON, M5T1P7, Canada.,Dalla Lana School of Public Health, University of Toronto, 155 College, Toronto, ON, M5T 3M7, Canada
| | - Aliya Noormohamed
- Nicotine Dependence Services, Centre for Addiction and Mental Health, 175 College St, Toronto, ON, M5T1P7, Canada
| | - Laurie Zawertailo
- Nicotine Dependence Services, Centre for Addiction and Mental Health, 175 College St, Toronto, ON, M5T1P7, Canada.,Department of Pharmacology and Toxicology, University of Toronto, 1 King's College Cir, Toronto, ON, M5S 1A8, Canada
| | - Norman Giesbrecht
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health, 33 Russell St, Toronto, ON, M5S 2S1, Canada
| | - Christian S Hendershot
- Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, 60 White Squirrel Way, Toronto, ON, M6J 1H4, Canada.,Department of Psychiatry, University of Toronto, 250 College Street, Toronto, ON, M5T 1R8, Canada
| | - Bernard Le Foll
- Department of Family and Community Medicine, University of Toronto, 500 University Ave, Toronto, ON, M5G 1V7, Canada.,Department of Pharmacology and Toxicology, University of Toronto, 1 King's College Cir, Toronto, ON, M5S 1A8, Canada.,Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, 60 White Squirrel Way, Toronto, ON, M6J 1H4, Canada.,Department of Psychiatry, University of Toronto, 250 College Street, Toronto, ON, M5T 1R8, Canada
| | - Jürgen Rehm
- Dalla Lana School of Public Health, University of Toronto, 155 College, Toronto, ON, M5T 3M7, Canada.,Institute for Mental Health Policy Research, Centre for Addiction and Mental Health, 33 Russell St, Toronto, ON, M5S 2S1, Canada.,Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, 60 White Squirrel Way, Toronto, ON, M6J 1H4, Canada.,Department of Psychiatry, University of Toronto, 250 College Street, Toronto, ON, M5T 1R8, Canada.,Institute of Medical Science, University of Toronto, 1 King's College Cir, Toronto, ON, M5S 3K1, Canada.,Institute for Clinical Psychology and Psychotherapy, TU Dresden, Chemnitzer Str. 46, 01187, Dresden, Germany
| | - Andriy V Samokhvalov
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health, 33 Russell St, Toronto, ON, M5S 2S1, Canada.,Department of Psychiatry, University of Toronto, 250 College Street, Toronto, ON, M5T 1R8, Canada.,Institute of Medical Science, University of Toronto, 1 King's College Cir, Toronto, ON, M5S 3K1, Canada
| | - Peter L Selby
- Nicotine Dependence Services, Centre for Addiction and Mental Health, 175 College St, Toronto, ON, M5T1P7, Canada. .,Department of Family and Community Medicine, University of Toronto, 500 University Ave, Toronto, ON, M5G 1V7, Canada. .,Dalla Lana School of Public Health, University of Toronto, 155 College, Toronto, ON, M5T 3M7, Canada. .,Department of Psychiatry, University of Toronto, 250 College Street, Toronto, ON, M5T 1R8, Canada.
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Abstract
CLINICAL ISSUE Acute abdominal pain is a prevalent problem in the emergency department. The work-up has to include a broad spectrum of differential diagnoses, which should be narrowed down with respect to frequent diagnoses without overlooking rare but potentially even more severe pathologies. STANDARD RADIOLOGICAL METHODS The radiological method of choice for the initial work-up after sonography is computed tomography, which has demonstrated the highest sensitivity and specificity for most findings. Plain film radiographs of the abdomen rarely contribute to the final diagnosis. Magnetic resonance imaging is reserved for selected cases, which are described in this article. ASSESSMENT The clinical decision trees and recommendations, which need to be in the report depending on the diagnosis, are of relevance for every radiologist who deals with patients with acute abdominal presentations. PRACTICAL RECOMMENDATIONS Knowledge of the clinical diagnostic approach in patients with acute abdomen is an unavoidable prerequisite for optimal cooperation between clinicians and radiologists in acute situations.
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Affiliation(s)
- D Tamandl
- Universitätsklinik für Radiologie und Nuklearmedizin, Medizinische Universität Wien, Währinger Gürtel 18-20, 1090, Wien, Österreich.
| | - T Uray
- Universitätsklinik für Notfallmedizin, Medizinische Universität Wien, Währinger Gürtel 18-20, Wien, Österreich
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Abstract
Introduction Scoring systems such as the Modified Alvarado Score (MAS) can help in the early diagnosis of acute appendicitis (AA) but is cumbersome to use and has not found widespread popularity. A more robust, user-friendly Simplified Appendicitis Score (SAS) was investigated. Methods Patients presenting with suspected AA were prospectively enrolled. The performance of the SAS (using only 5 variables – migratory pain, right lower quadrant tenderness, rebound pain, fever >37.3 degrees Celsius and leucocytosis >12,000/uL) was analysed and compared to the MAS. Results Out of 238 patients enrolled over four months, 95 (39.9%) patients underwent appendectomy, of which 81 patients had histologically proven AA. A MAS of ≥8 was 92.4% specific for ruling in AA, while a score of <5 was 91.4% sensitive in ruling out AA. A SAS of ≥6 was 91.7% specific for ruling in AA, while a score of <4 was 90.1% sensitive in ruling out AA. Conclusions The performance of the MAS can be maintained by omitting the two subjective variables – “anorexia” and “nausea/vomiting”, and increasing the leucocytosis cut-off level. A SAS using only 5 variables performed as well as the original MAS.
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Gamst-Jensen H, Lippert FK, Egerod I. Under-triage in telephone consultation is related to non-normative symptom description and interpersonal communication: a mixed methods study. Scand J Trauma Resusc Emerg Med 2017; 25:52. [PMID: 28506282 PMCID: PMC5433057 DOI: 10.1186/s13049-017-0390-0] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2016] [Accepted: 04/26/2017] [Indexed: 11/10/2022] Open
Abstract
Background Telephone consultation and triage are used to limit the workload on emergency departments. Lack of visual cues and clinical tests put telephone consultations to a disadvantage compared to face-to-face consultations increasing the risk of under-triage. Under-triage occurs in telephone triage; however why under-triage happens is not explored yet. The aim of the study was to describe situations of under-triage in context, to assess the quality of under-triaged calls, and to identify communication patterns contributing to under-triage in a regional OOH service in the capital region of Denmark. Methods Explanatory simultaneous mixed method with thematic analysis and descriptive statistics was chosen. The study was carried out in an Out-Of-Hours service (OOH) in the Capital Region of Denmark, Copenhagen. Under-triage was defined as Potentially Under-Triaged Calls (PUTC) by specific criteria to an OOH Hotline, and identification by integration of three databases: Medical Hotline database, Emergency number database, including the Ambulance database, and electronic patient records. Distribution of PUTC were carried out using ICD-10 codes to identify diagnosis and main themes identified by qualitative analysis of audio recorded under-triaged calls. Study period was October 15th to November 30th 2014. Results Three hundred twenty seven PUTC were identified, representing 0.04% of all calls (n = 937.056) to the OOH. Distribution of PUTC according to diagnoses was: digestive (24%), circulatory (19%), respiratory (15%) and all others (42%). Thematic analysis of the voice logs suggested that inadequate communication and non-normative symptom description contributed to under-triage. Discussion The incidence of potentially under-triage is low (0.04%). However, the over-representation of digestive, circulatory, and respiratory diagnoses might suggest that under-triage is related to inadequate symptom description. We recommend that caller and call-handler collaborate systematically on problem identification and negotiate non-normative symptom description. Conclusion The incidence of under-triage is low (0.04%). However, the over-representation of digestive, circulatory, and respiratory diagnoses might suggest that under-triage is related to inadequate symptom description. We recommend that caller and call-handler collaborate systematically on problem identification and negotiate non-normative symptom description.
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Affiliation(s)
- Hejdi Gamst-Jensen
- Emergency Medical Services Copenhagen, University of Copenhagen, Telegrafvej 5, 2. Sal, 2750, Ballerup, Denmark.
| | - Freddy K Lippert
- Emergency Medical Services Copenhagen, University of Copenhagen, Telegrafvej 5, 2. Sal, 2750, Ballerup, Denmark
| | - Ingrid Egerod
- Trauma Centre, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, 2100, Copenhagen, Denmark
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Sanders SL, Rathbone J, Bell KJL, Glasziou PP, Doust JA. Systematic review of the effects of care provided with and without diagnostic clinical prediction rules. Diagn Progn Res 2017; 1:13. [PMID: 31093542 PMCID: PMC6460683 DOI: 10.1186/s41512-017-0013-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Accepted: 04/06/2017] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Diagnostic clinical prediction rules (CPRs) are worthwhile if they improve patient outcomes or provide benefits such as reduced resource use, without harming patients. We conducted a systematic review to assess the effects of diagnostic CPRs on patient and process of care outcomes. METHODS We searched electronic databases and a trial registry and performed citation and reference checks, for randomised trials comparing a diagnostic strategy with and without a CPR. Included studies were assessed for risk of bias and similar studies meta-analysed. RESULTS Twenty-seven studies evaluating diagnostic CPRs for 14 conditions were included. A clinical management decision was the primary outcome in the majority of studies. Most studies were judged to be at high or uncertain risk of bias on ≥3 of 6 domains. Details of study interventions and implementation were infrequently reported.For suspected Group A Streptococcus throat infection, diagnostic CPRs reduced symptoms (1 study) and antibiotic prescriptions (5 studies, RR 0.86, 95% CI 0.75 to 0.99). For suspected cardiac chest pain, diagnostic strategies incorporating a CPR improved early discharge rates (1 study), decreased objective cardiac testing (1 study) and decreased hospitalisations (1 study). For ankle injuries, Ottawa Ankle Rules reduced radiography when used with clinical examination (1 study) but had no effect on length of stay as a triage test (1 study). For suspected acute appendicitis, CPRs had no effect on rates of perforated appendix (1 study) or the number of non-therapeutic operations (5 studies, RR 0.68, 95% CI 0.43 to 1.08). For suspected pneumonia, CPRs reduced antibiotic prescribing without unfavourable outcomes (3 studies). For children with possible serious bacterial infection, diagnostic CPRs did not improve process of care outcomes (3 studies). CONCLUSION There are few randomised trials of diagnostic CPRs, and patient outcomes are infrequently reported. Diagnostic CPRs had a positive effect on process outcomes in some clinical conditions; however, many studies were at unclear or high risk of bias and the results may be context specific. Future studies should seek to detail how the CPR might alter the diagnostic pathway, report effects on both patient and process outcomes, and improve reporting of the study interventions and implementation. TRIAL REGISTRATION The protocol for this review was not registered with PROSPERO, the international prospective register of systematic review protocols. The review was conceived and protocol prepared prior to the launch of PROSPERO in February 2011.
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Affiliation(s)
- Sharon L Sanders
- 1Centre for Research in Evidence-Based Practice, Bond University, Gold Coast, Queensland Australia
| | - John Rathbone
- 1Centre for Research in Evidence-Based Practice, Bond University, Gold Coast, Queensland Australia
| | - Katy J L Bell
- 1Centre for Research in Evidence-Based Practice, Bond University, Gold Coast, Queensland Australia
- 2Sydney School of Public Health, Sydney Medical School, The University of Sydney, Sydney, Australia
| | - Paul P Glasziou
- 1Centre for Research in Evidence-Based Practice, Bond University, Gold Coast, Queensland Australia
| | - Jenny A Doust
- 1Centre for Research in Evidence-Based Practice, Bond University, Gold Coast, Queensland Australia
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Closs SJ, Dowding D, Allcock N, Hulme C, Keady J, Sampson EL, Briggs M, Corbett A, Esterhuizen P, Holmes J, James K, Lasrado R, Long A, McGinnis E, O’Dwyer J, Swarbrick C, Lichtner V. Towards improved decision support in the assessment and management of pain for people with dementia in hospital: a systematic meta-review and observational study. Health Serv Deliv Res 2016. [DOI: 10.3310/hsdr04300] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
BackgroundPain and dementia are common in older people, and impaired cognitive abilities make it difficult for them to communicate their pain. Pain, if poorly managed, impairs health and well-being. Accurate pain assessment in this vulnerable group is challenging for hospital staff, but essential for appropriate management. Robust methods for identifying, assessing and managing pain are needed.Aims and objectivesTwo studies were undertaken to inform the development of a decision support tool to aid hospital staff in the recognition, assessment and management of pain. The first was a meta-review of systematic reviews of observational pain assessment instruments with three objectives: (1) to identify the tools available to assess pain in adults with dementia; (2) to identify in which settings they were used and with what patient populations; and (3) to assess their reliability, validity and clinical utility. The second was a multisite observational study in hospitals with four objectives: (1) to identify information currently used by clinicians when detecting and managing pain in patients with dementia; (2) to explore existing processes for detecting and managing pain in these patients; (3) to identify the role (actual/potential) of carers in this process; and (4) to explore the organisational context in which health professionals operate. Findings also informed development of health economics data collection forms to evaluate the implementation of a new decision support intervention in hospitals.MethodsFor the meta-review of systematic reviews, 12 databases were searched. Reviews of observational pain assessment instruments that provided psychometric data were included. Papers were quality assessed and data combined using narrative synthesis. The observational study used an ethnographic approach in 11 wards in four UK hospitals. This included non-participant observation of 31 patients, audits of patient records, semistructured interviews with 52 staff and four carers, informal conversations with staff and carers and analysis of ward documents and policies. Thematic analysis of the data was undertaken by the project team.ResultsData from eight systematic reviews including 28 tools were included in the meta-review. Most tools showed moderate to good reliability, but information about validity, feasibility and clinical utility was scarce. The observational study showed complex ward cultures and routines, with variations in time spent with patients, communication patterns and management practices. Carer involvement was rare. No pain decision support tools were observed in practice. Information about pain was elicited in different ways, at different times, by different health-care staff and recorded in separate documents. Individual staff made sense of patients’ pain by creating their own ‘overall picture’ from available information.LimitationsGrey literature and non-English-language papers were excluded from the meta-review. Sample sizes in the observational study were smaller than planned owing to poor documentation of patients’ dementia diagnoses, gatekeeping by staff and difficulties in gaining consent/assent. Many patients had no or geographically distant carers, or a spouse who was too unwell and/or reluctant to participate.ConclusionsNo single observational pain scale was clearly superior to any other. The traditional linear concept of pain being assessed, treated and reassessed by single individuals did not ‘fit’ with clinical reality. A new approach enabling effective communication among patients, carers and staff, centralised recording of pain-related information, and an extended range of pain management interventions is proposed [Pain And Dementia Decision Support (PADDS)]. This was not tested with users, but a follow-on study aims to codesign PADDS with carers and clinicians, then introduce education on staff/patient/carer communications and use of PADDS within a structured implementation plan. PADDS will need to be tested in differing ward contexts.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- S José Closs
- School of Healthcare, University of Leeds, Leeds, UK
| | - Dawn Dowding
- School of Nursing, Columbia University, New York, NY, USA
- Center for Home Care Policy and Research, Visiting Nurse Service of New York, New York, NY, USA
| | - Nick Allcock
- Clinical Specialist, Pain Management Solutions, Nottingham, UK
| | - Claire Hulme
- Leeds Institute for Health Sciences, University of Leeds, Leeds, UK
| | - John Keady
- School of Nursing, Midwifery and Social Work, University of Manchester, Manchester, UK
| | | | - Michelle Briggs
- School of Health and Community Studies, Leeds Beckett University, Leeds, UK
| | - Anne Corbett
- Wolfson Centre for Age-Related Diseases, King’s College London, London, UK
| | | | - John Holmes
- Leeds Institute of Medical Education, University of Leeds, Leeds, UK
| | - Kirstin James
- School of Health, Nursing and Midwifery, University of the West of Scotland, Paisley, UK
| | - Reena Lasrado
- School of Nursing, Midwifery and Social Work, University of Manchester, Manchester, UK
| | - Andrew Long
- School of Healthcare, University of Leeds, Leeds, UK
| | | | - John O’Dwyer
- Leeds Institute for Health Sciences, University of Leeds, Leeds, UK
| | - Caroline Swarbrick
- School of Nursing, Midwifery and Social Work, University of Manchester, Manchester, UK
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Nurek M, Kostopoulou O, Delaney BC, Esmail A. Reducing diagnostic errors in primary care. A systematic meta-review of computerized diagnostic decision support systems by the LINNEAUS collaboration on patient safety in primary care. Eur J Gen Pract 2016; 21 Suppl:8-13. [PMID: 26339829 PMCID: PMC4828626 DOI: 10.3109/13814788.2015.1043123] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background: Computerized diagnostic decision support systems (CDDSS) have the potential to support the cognitive task of diagnosis, which is one of the areas where general practitioners have greatest difficulty and which accounts for a significant proportion of adverse events recorded in the primary care setting. Objective: To determine the extent to which CDDSS may meet the requirements of supporting the cognitive task of diagnosis, and the currently perceived barriers that prevent the integration of CDDSS with electronic health record (EHR) systems. Methods: We conducted a meta-review of existing systematic reviews published in English, searching MEDLINE, Embase, PsycINFO and Web of Knowledge for articles on the features and effectiveness of CDDSS for medical diagnosis published since 2004. Eligibility criteria included systematic reviews where individual clinicians were primary end users. Outcomes we were interested in were the effectiveness and identification of specific features of CDDSS on diagnostic performance. Results: We identified 1970 studies and excluded 1938 because they did not fit our inclusion criteria. A total of 45 articles were identified and 12 were found suitable for meta-review. Extraction of high-level requirements identified that a more standardized computable approach is needed to knowledge representation, one that can be readily updated as new knowledge is gained. In addition, a deep integration with the EHR is needed in order to trigger at appropriate points in cognitive workflow. Conclusion: Developing a CDDSS that is able to utilize dynamic vocabulary tools to quickly capture and code relevant diagnostic findings, and coupling these with individualized diagnostic suggestions based on the best-available evidence has the potential to improve diagnostic accuracy, but requires evaluation.
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Affiliation(s)
- Martine Nurek
- a King's College London, Department of Primary Care and Public Health Sciences , London , UK
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Sanders S, Doust J, Glasziou P. A systematic review of studies comparing diagnostic clinical prediction rules with clinical judgment. PLoS One 2015; 10:e0128233. [PMID: 26039538 DOI: 10.1371/journal.pone.0128233] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2014] [Accepted: 04/24/2015] [Indexed: 11/20/2022] Open
Abstract
Background Diagnostic 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 Findings We 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. Conclusions In 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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Macey R, Walsh T, Brocklehurst P, Kerr AR, Liu JLY, Lingen MW, Ogden GR, Warnakulasuriya S, Scully C. Diagnostic tests for oral cancer and potentially malignant disorders in patients presenting with clinically evident lesions. Cochrane Database Syst Rev 2015; 2015:CD010276. [PMID: 26021841 PMCID: PMC7087440 DOI: 10.1002/14651858.cd010276.pub2] [Citation(s) in RCA: 67] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Oral squamous cell carcinoma is the most common form of malignancy of the lip and oral cavity, often being proceeded by potentially malignant disorders (PMD). Early detection can reduce the malignant transformation of PMD and can improve the survival rate for oral cancer. The current standard of scalpel biopsy with histology is painful for patients and involves a delay whilst histology is completed; other tests are available that are unobtrusive and provide immediate results. OBJECTIVES PRIMARY OBJECTIVE To estimate the diagnostic accuracy of index tests for the detection of oral cancer and PMD of the lip and oral cavity, in people presenting with clinically evident lesions. SECONDARY OBJECTIVE To estimate the relative accuracy of the different index tests. SEARCH METHODS The electronic databases were searched on 30 April 2013. We searched MEDLINE (OVID) (1946 to April 2013) and four other electronic databases (the Cochrane Diagnostic Test Accuracy Studies Register, the Cochrane Oral Health Group's Trials Register, EMBASE (OVID) and MEDION (Ovid)). There were no restrictions on language in the searches of the electronic databases. We conducted citation searches and screened reference lists of included studies for additional references. SELECTION CRITERIA We selected studies that reported the diagnostic test accuracy of the following index tests when used as an adjunct to conventional oral examination in detecting PMD or oral squamous cell carcinoma of the lip or oral cavity: vital staining, oral cytology, light-based detection and oral spectroscopy, blood or saliva analysis (which test for the presence of biomarkers in blood or saliva). DATA COLLECTION AND ANALYSIS Two review authors independently screened titles and abstracts for relevance. Eligibility, data extraction and quality assessment were carried out by at least two authors, independently and in duplicate. Studies were assessed for methodological quality using QUADAS-2. Meta-analysis was used to combine the results of studies for each index test using the bivariate approach to estimate the expected values of sensitivity and specificity. MAIN RESULTS We included 41 studies, recruiting 4002 participants, in this review. These studies evaluated the diagnostic accuracy of conventional oral examination with: vital staining (14 studies), oral cytology (13 studies), light-based detection or oral spectroscopy (13 studies). Six studies assessed two combined index tests. There were no eligible diagnostic accuracy studies evaluating blood or salivary sample analysis.The summary estimates for vital staining obtained from the meta-analysis were sensitivity of 0.84 (95% CI 0.74 to 0.90) with specificity of 0.70 (0.59 to 0.79), with 14 studies were included in the meta-analysis. For cytology, sensitivity was 0.91 (0.81 to 0.96) and specificity was 0.91 (0.81 to 0.95) with 12 studies included in the meta-analysis. For light-based detection, sensitivity was 0.91 (0.77 to 0.97) and specificity was 0.58 (0.22 to 0.87) with 11 studies included in the meta-analysis. The relative test accuracy was assessed by adding covariates to the bivariate analysis, no difference in model fit was observed. AUTHORS' CONCLUSIONS The overall quality of the included studies was poor. None of the adjunctive tests can be recommended as a replacement for the currently used standard of a scalpel biopsy and histological assessment. Given the relatively high values of the summary estimates of sensitivity and specificity for cytology, this would appear to offer the most potential. Combined adjunctive tests involving cytology warrant further investigation.
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Affiliation(s)
- Richard Macey
- School of Dentistry, The University of ManchesterCoupland 3 BuildingOxford RoadManchesterUKM13 9PL
| | - Tanya Walsh
- School of Dentistry, The University of ManchesterCoupland 3 BuildingOxford RoadManchesterUKM13 9PL
| | - Paul Brocklehurst
- Bangor UniversityNWORTH CTUY Wern (Normal Site)Holyhead RoadBangorUKLL57 2PZ
| | - Alexander R Kerr
- New York University College of DentistryDepartment of Oral and Maxillofacial Pathology, Radiology and Medicine345 East 24th StreetSchwartz BuildingNew YorkUSA10010
| | - Joseph LY Liu
- Scottish Dental Clinical Effectiveness Programme, NHS Education for ScotlandUniversity of Dundee, Dental Health Services Research UnitFrankland Building, Small's WyndDundeeUKDD1 4HN
| | - Mark W Lingen
- University of ChicagoPritzker School of Medicine, Division of Biological Sciences, Department of Pathology5841 South Maryland AvenueChicagoIllinoisUSA60637‐1470
| | - Graham R Ogden
- University of DundeeDivision of Oral and Maxillofacial Clinical Sciences, School of DentistryPark PlaceDundeeScotlandUKDD1 4HR
| | - Saman Warnakulasuriya
- King's College LondonClinical and Diagnostic SciencesBessemer RoadDenmark Hill CampusLondonUKSE5 9RW
| | - Crispian Scully
- University College London256 Gray's Inn RoadLondonUKWC1X 8LD
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13
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Liu W, de Virgilio C, Grigorian A, Arnell TD. Right Lower Quadrant Abdominal Pain. Surgery 2015. [DOI: 10.1007/978-1-4939-1726-6_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Lichtner V, Dowding D, Esterhuizen P, Closs SJ, Long AF, Corbett A, Briggs M. Pain assessment for people with dementia: a systematic review of systematic reviews of pain assessment tools. BMC Geriatr 2014; 14:138. [PMID: 25519741 PMCID: PMC4289543 DOI: 10.1186/1471-2318-14-138] [Citation(s) in RCA: 153] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2014] [Accepted: 12/11/2014] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND There is evidence of under-detection and poor management of pain in patients with dementia, in both long-term and acute care. Accurate assessment of pain in people with dementia is challenging and pain assessment tools have received considerable attention over the years, with an increasing number of tools made available. Systematic reviews on the evidence of their validity and utility mostly compare different sets of tools. This review of systematic reviews analyses and summarises evidence concerning the psychometric properties and clinical utility of pain assessment tools in adults with dementia or cognitive impairment. METHODS We searched for systematic reviews of pain assessment tools providing evidence of reliability, validity and clinical utility. Two reviewers independently assessed each review and extracted data from them, with a third reviewer mediating when consensus was not reached. Analysis of the data was carried out collaboratively. The reviews were synthesised using a narrative synthesis approach. RESULTS We retrieved 441 potentially eligible reviews, 23 met the criteria for inclusion and 8 provided data for extraction. Each review evaluated between 8 and 13 tools, in aggregate providing evidence on a total of 28 tools. The quality of the reviews varied and the reporting often lacked sufficient methodological detail for quality assessment. The 28 tools appear to have been studied in a variety of settings and with varied types of patients. The reviews identified several methodological limitations across the original studies. The lack of a 'gold standard' significantly hinders the evaluation of tools' validity. Most importantly, the samples were small providing limited evidence for use of any of the tools across settings or populations. CONCLUSIONS There are a considerable number of pain assessment tools available for use with the elderly cognitive impaired population. However there is limited evidence about their reliability, validity and clinical utility. On the basis of this review no one tool can be recommended given the existing evidence.
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Affiliation(s)
| | - Dawn Dowding
- />Columbia University School of Nursing, 617 West 168th Street, New York, NY 10032 USA
- />Center for Home Care Policy and Research, Visiting Nurse Service of New York, 5 Penn Plaza, New York, NY 10001 USA
| | | | - S José Closs
- />School of Healthcare, University of Leeds, Leeds, UK
| | - Andrew F Long
- />School of Healthcare, University of Leeds, Leeds, UK
| | - Anne Corbett
- />Wolfson Centre for Age-Related Diseases, King’s College London, London, SE1 1UL UK
| | - Michelle Briggs
- />Institute of Health and Wellbeing, Leeds Beckett University, Leeds, UK
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Higashi H, Barendregt JJ, Kassebaum NJ, Weiser TG, Bickler SW, Vos T. Surgically avertable burden of digestive diseases at first-level hospitals in low and middle-income regions. Surgery 2014; 157:411-9; discussion 420-2. [PMID: 25444219 DOI: 10.1016/j.surg.2014.07.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2013] [Accepted: 07/16/2014] [Indexed: 01/06/2023]
Abstract
BACKGROUND To quantify the burden of digestive diseases avertable by surgical care at first-level hospitals in low- and middle-income countries (LMICs). METHODS We examined 4 digestive diseases from the Global Burden of Disease (GBD) 2010 STUDY: Appendicitis, intestinal obstruction, inguinal and femoral hernia, and gallbladder and bile duct disease. Using demographic and epidemiologic data from the GBD 2010 STUDY, we calculated the potential decrease in burden of digestive diseases if quality surgical services were available universally and accessible at first-level hospitals. The lowest case fatality rates for each age and sex grouping from all GBD regions were assumed to reflect the best possible state of full surgical coverage and treatment. These best scenario rates were applied to the GBD 2010 results from all LMIC regions to estimate surgically avertable burden. RESULTS Overall, 4.8 million disability-adjusted life-years (DALYs) or 65% of burden related to the 4 digestive diseases are avertable potentially with first-level surgical care in LMICs. Sub-Saharan Africa has the greatest avertable burden in absolute DALYs (1.7 million) and avertable proportion (83%). Intestinal obstruction accounted for the largest portion of avertable burden among the 4 digestive diseases (2.2 million DALYs; 64% avertable). CONCLUSION Improving the capacity of surgical services at first-level hospitals is essential for averting the burden of digestive diseases in LMICs. Practicable strategies for scaling up surgical capacities in rural districts are available potentially, which must be given due attention.
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Affiliation(s)
- Hideki Higashi
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA; School of Population Health, University of Queensland, Brisbane, Queensland, Australia.
| | - Jan J Barendregt
- School of Population Health, University of Queensland, Brisbane, Queensland, Australia
| | - Nicholas J Kassebaum
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA; Division of Anesthesiology & Pain Medicine, Seattle Children's Hospital, Seattle, WA
| | - Thomas G Weiser
- Department of Surgery, School of Medicine, Stanford University, Stanford, CA
| | - Stephen W Bickler
- Department of Surgery, School of Medicine, University of California, San Diego, CA
| | - Theo Vos
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA; School of Population Health, University of Queensland, Brisbane, Queensland, Australia
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Ebell MH, Shinholser J. What are the most clinically useful cutoffs for the Alvarado and Pediatric Appendicitis Scores? A systematic review. Ann Emerg Med 2014; 64:365-372.e2. [PMID: 24731432 DOI: 10.1016/j.annemergmed.2014.02.025] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2013] [Revised: 01/25/2014] [Accepted: 02/28/2014] [Indexed: 12/13/2022]
Abstract
STUDY OBJECTIVE The objective of this study is to systematically review the accuracy of the Alvarado score and Pediatric Appendicitis Score and to identify optimal cutoffs for low- and high-risk populations. METHODS We performed a systematic review of the literature and identified 26 studies of the accuracy of the Alvarado score and Pediatric Appendicitis Score. Data were abstracted in parallel, and only prospective, cohort studies that avoided verification bias were included. We calculated summary likelihood ratios for low-, moderate-, and high-risk groups, using all possible cutoffs based on available data, even if not reported in the original study. RESULTS The pretest probability of appendicitis was approximately 33% in studies of children and approximately 66% in studies of adults. Likelihood ratios at different cutoffs for the Alvarado score in adults were as follows: 0.03 (<4 points), 0.42 (4 to 6 points), and 3.4 (≥ 7 points); and 0.01 (<5 points), 0.98 (5 to 8 points), and 6.7 (≥ 9 points). Likelihood ratios for the Alvarado score in children were as follows: 0.02 (<4 points), 0.27 (4 to 6 points), and 4.2 (≥ 7 points); and 0.04 (<5 points), 1.2 (5 to 8 points), and 8.5 (≥ 9 points). For the Pediatric Appendicitis Score, likelihood ratios were 0.13 (<4 points), 0.70 (4 to 7 points), and 8.1 (≥ 8 points). CONCLUSION For children with a pretest probability of acute appendicitis of 60% or less, an Alvarado score below 4 rules out the diagnosis; this is also true for a score less than 5 if the pretest probability is up to approximately 40%. In adults with a pretest probability greater than or equal to 60%, an Alvarado score of 8 or higher rules in the diagnosis, whereas one of 9 or higher rules in the diagnosis at pretest probabilities greater than or equal to 40%. The Pediatric Appendicitis Score did not identify clinically useful low- or high-risk groups at typical pretest probabilities.
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Affiliation(s)
- Mark H Ebell
- Department of Epidemiology and Biostatistics, College of Public Health, University of Georgia, Athens, GA.
| | - JoAnna Shinholser
- Department of Epidemiology and Biostatistics, College of Public Health, University of Georgia, Athens, GA
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Stoneham M, Murray D, Foss N. Emergency surgery: the big three - abdominal aortic aneurysm, laparotomy and hip fracture. Anaesthesia 2013; 69 Suppl 1:70-80. [DOI: 10.1111/anae.12492] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/01/2013] [Indexed: 01/23/2023]
Affiliation(s)
- M. Stoneham
- Nuffield Division of Anaesthetics; Oxford University Hospitals NHS Trust; Oxford UK
| | - D. Murray
- James Cook University Hospital; Middlesbrough UK
| | - N. Foss
- Department of Anaesthesia; Hvidovre University Hospital; Copenhagen Denmark
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Walsh T, Liu JLY, Brocklehurst P, Glenny A, Lingen M, Kerr AR, Ogden G, Warnakulasuriya S, Scully C. Clinical assessment to screen for the detection of oral cavity cancer and potentially malignant disorders in apparently healthy adults. Cochrane Database Syst Rev 2013; 2013:CD010173. [PMID: 24258195 PMCID: PMC7087434 DOI: 10.1002/14651858.cd010173.pub2] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND The early detection and excision of potentially malignant disorders (PMD) of the lip and oral cavity that require intervention may reduce malignant transformations (though will not totally eliminate malignancy occurring), or if malignancy is detected during surveillance, there is some evidence that appropriate treatment may improve survival rates. OBJECTIVES To estimate the diagnostic accuracy of conventional oral examination (COE), vital rinsing, light-based detection, biomarkers and mouth self examination (MSE), used singly or in combination, for the early detection of PMD or cancer of the lip and oral cavity in apparently healthy adults. SEARCH METHODS We searched MEDLINE (OVID) (1946 to April 2013) and four other electronic databases (the Cochrane Diagnostic Test Accuracy Studies Register, the Cochrane Oral Health Group's Trials Register, EMBASE (OVID), and MEDION) from inception to April 2013. The electronic databases were searched on 30 April 2013. There were no restrictions on language in the searches of the electronic databases. We conducted citation searches, and screened reference lists of included studies for additional references. SELECTION CRITERIA We selected studies that reported the diagnostic test accuracy of any of the aforementioned tests in detecting PMD or cancer of the lip or oral cavity. Diagnosis of PMD or cancer was made by specialist clinicians or pathologists, or alternatively through follow-up. DATA COLLECTION AND ANALYSIS Two review authors independently screened titles and abstracts for relevance. Eligibility, data extraction and quality assessment were carried out by at least two authors independently and in duplicate. Studies were assessed for methodological quality using QUADAS-2. We reported the sensitivity and specificity of the included studies. MAIN RESULTS Thirteen studies, recruiting 68,362 participants, were included. These studies evaluated the diagnostic accuracy of COE (10 studies), MSE (two studies). One randomised controlled of test accuracy trial directly evaluated COE and vital rinsing. There were no eligible diagnostic accuracy studies evaluating light-based detection or blood or salivary sample analysis (which tests for the presence of bio-markers of PMD and oral cancer). Given the clinical heterogeneity of the included studies in terms of the participants recruited, setting, prevalence of target condition, the application of the index test and reference standard and the flow and timing of the process, the data could not be pooled. For COE (10 studies, 25,568 participants), prevalence in the diagnostic test accuracy sample ranged from 1% to 51%. For the eight studies with prevalence of 10% or lower, the sensitivity estimates were highly variable, and ranged from 0.50 (95% confidence interval (CI) 0.07 to 0.93) to 0.99 (95% CI 0.97 to 1.00) with uniform specificity estimates around 0.98 (95% CI 0.97 to 1.00). Estimates of sensitivity and specificity were 0.95 (95% CI 0.92 to 0.97) and 0.81 (95% CI 0.79 to 0.83) for one study with prevalence of 22% and 0.97 (95% CI 0.96 to 0.98) and 0.75 (95% CI 0.73 to 0.77) for one study with prevalence of 51%. Three studies were judged to be at low risk of bias overall; two were judged to be at high risk of bias resulting from the flow and timing domain; and for five studies the overall risk of bias was judged as unclear resulting from insufficient information to form a judgement for at least one of the four quality assessment domains. Applicability was of low concern overall for two studies; high concern overall for three studies due to high risk population, and unclear overall applicability for five studies. Estimates of sensitivity for MSE (two studies, 34,819 participants) were 0.18 (95% CI 0.13 to 0.24) and 0.33 (95% CI 0.10 to 0.65); specificity for MSE was 1.00 (95% CI 1.00 to 1.00) and 0.54 (95% CI 0.37 to 0.69). One study (7975 participants) directly compared COE with COE plus vital rinsing in a randomised controlled trial. This study found a higher detection rate for oral cavity cancer in the conventional oral examination plus vital rinsing adjunct trial arm. AUTHORS' CONCLUSIONS The prevalence of the target condition both between and within index tests varied considerably. For COE estimates of sensitivity over the range of prevalence levels varied widely. Observed estimates of specificity were more homogeneous. Index tests at a prevalence reported in the population (between 1% and 5%) were better at correctly classifying the absence of PMD or oral cavity cancer in disease-free individuals that classifying the presence in diseased individuals. Incorrectly classifying disease-free individuals as having the disease would have clinical and financial implications following inappropriate referral; incorrectly classifying individuals with the disease as disease-free will mean PMD or oral cavity cancer will only be diagnosed later when the disease will be more severe. General dental practitioners and dental care professionals should remain vigilant for signs of PMD and oral cancer whilst performing routine oral examinations in practice.
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Affiliation(s)
- Tanya Walsh
- School of Dentistry, The University of ManchesterCoupland III Building, Oxford RoadManchesterUKM13 9PL
| | - Joseph LY Liu
- Scottish Dental Clinical Effectiveness Programme, NHS Education for ScotlandUniversity of Dundee, Dental Health Services Research UnitFrankland Building, Small's WyndDundeeUKDD1 4HN
| | - Paul Brocklehurst
- School of Dentistry, The University of ManchesterCoupland III Building, Oxford RoadManchesterUKM13 9PL
| | - Anne‐Marie Glenny
- School of Dentistry, The University of ManchesterCochrane Oral Health GroupCoupland III Building, Oxford RoadManchesterUKM13 9PL
| | - Mark Lingen
- University of ChicagoPritzker School of Medicine, Division of Biological Sciences, Department of Pathology5841 South Maryland AvenueChicagoIllinoisUSA60637‐1470
| | - Alexander R Kerr
- New York University College of DentistryDepartment of Oral and Maxillofacial Pathology, Radiology and Medicine345 East 24th StreetSchwartz BuildingNew YorkUSA10010
| | - Graham Ogden
- University of DundeeDivision of Oral and Maxillofacial Clinical Sciences, School of DentistryPark PlaceDundeeScotlandUKDD1 4HR
| | - Saman Warnakulasuriya
- King's College LondonClinical and Diagnostic SciencesBessemer RoadDenmark Hill CampusLondonUKSE5 9RW
| | - Crispian Scully
- University College London256 Gray's Inn RoadLondonUKWC1X 8LD
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Rodríguez-González A, Torres-Niño J, Valencia-Garcia R, Mayer MA, Alor-Hernandez G. Using experts feedback in clinical case resolution and arbitration as accuracy diagnosis methodology. Comput Biol Med 2013; 43:975-86. [DOI: 10.1016/j.compbiomed.2013.05.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2012] [Revised: 05/02/2013] [Accepted: 05/04/2013] [Indexed: 10/26/2022]
Affiliation(s)
- Alejandro Rodríguez-González
- Bioinformatics at the Centre for Plant Biotechnology and Genomics UPM-INIA, Polytechnic University of Madrid, Parque Científico y Tecnológico de la U.P.M. Campus de Montegancedo, Pozuelo de Alarcón, 28223 Madrid, Spain.
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Mariotti G, Gentilini M, Dapor V. Improving referral activity on primary-secondary care interface using an electronic decision support system. Int J Med Inform 2013; 82:1144-51. [PMID: 24018243 DOI: 10.1016/j.ijmedinf.2013.08.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2012] [Revised: 07/31/2013] [Accepted: 08/06/2013] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Our main aim was to evaluate the ability of electronic feedback and of an electronic referral decision support system (ERSS) to enhance agreement between primary care physicians (PCPs) and specialists in priority assignment in clinics. METHOD 62 PCPs used a ranking system of waiting times based on different categories of clinical priority called 'Homogeneous Waiting Groups' (HWGs), which was also used by specialists to assign a priority category for each patient. From the year 2001, all PCPs had to use a paper-based manual (group 1); instead from 2008, specialists began to use a computer-based tool, whereby the priority category reassigned to each patient by specialists promptly appeared on PCPs' computers (group 2). During the course of 2010, the manual was incorporated in ERSS and was used by a subgroup of PCPs (group 3). Agreement between PCPs and specialists' priority assignments was evaluated by the kappa statistic. RESULTS In group 1, the kappa statistic was 0.564 (95% CI=0.526-0.602); in group 2, the kappa statistic was 0.668 (95% CI=0.619-0.716); whereas in group 3 (that used ERSS) a very high kappa statistic emerged of 0.883 (95% CI=0.854-0.912). There was a significant difference in the proportion of agreement among the three groups (χ(2)=182.5, 2df, p<.0001). A significant difference in statistics was also observed in the proportion of priority levels used by PCPs over the years. CONCLUSIONS Our results emphasize the positive effect of feedback and ERSS for improving referral activity and agreement between PCPs and specialists.
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Feldstein AC, Schneider JL, Unitan R, Perrin NA, Smith DH, Nichols GA, Lee NL. Health care worker perspectives inform optimization of patient panel-support tools: a qualitative study. Popul Health Manag 2012; 16:107-19. [PMID: 23216061 DOI: 10.1089/pop.2012.0065] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Electronic decision-support systems appear to enhance care, but improving both tools and work practices may optimize outcomes. Using qualitative methods, the authors' aim was to evaluate perspectives about using the Patient Panel-Support Tool (PST) to better understand health care workers' attitudes toward, and adoption and use of, a decision-support tool. In-depth interviews were conducted to elicit participant perspectives about the PST-an electronic tool implemented in 2006 at Kaiser Permanente Northwest. The PST identifies "care gaps" and recommendations in screening, medication use, risk-factor control, and immunizations for primary care panel patients. Primary care physician (PCP) teams were already grouped (based on performance pre- and post-PST introduction) into lower, improving, and higher percent-of-care-needs met. Participants were PCPs (n=21), medical assistants (n=11), and quality and other health care managers (n=20); total n=52. Results revealed that the most commonly cited benefit of the PST was increased in-depth knowledge of patient panels, and empowerment of staff to do quality improvement. Barriers to PST use included insufficient time, competing demands, suboptimal staffing, tool navigation, documentation, and data issues. Facilitators were strong team staff roles, leadership/training for tool implementation, and dedicated time for tool use. Higher performing PCPs and their assistants more often described a detailed team approach to using the PST. In conclusion, PCP teams and managers provided important perspectives that could help optimize use of panel-support tools to improve future outcomes. Improvements are needed in tool function and navigation; training; staff accountability and role clarification; and panel management time.
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Affiliation(s)
- Adrianne C Feldstein
- Center for Health Research , Kaiser Permanente Northwest, Portland, Oregon 97227, USA
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Bisig B, Moreira J, Combes M, Asiimwe A, Bisoffi Z, Haegeman F, Bottieau E, Van den Ende J. Does introduction of thresholds in decision aids benefit the patient?: Comparison between findings-based and threshold-based diagnostic decision aids. Med Decis Making 2012. [PMID: 23204241 DOI: 10.1177/0272989x12461854] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE To assess how different diagnostic decision aids perform in terms of sensitivity, specificity, and harm. METHODS Four diagnostic decision aids were compared, as applied to a simulated patient population: a findings-based algorithm following a linear or branched pathway, a serial threshold-based strategy, and a parallel threshold-based strategy. Headache in immune-compromised HIV patients in a developing country was used as an example. Diagnoses included cryptococcal meningitis, cerebral toxoplasmosis, tuberculous meningitis, bacterial meningitis, and malaria. Data were derived from literature and expert opinion. Diagnostic strategies' validity was assessed in terms of sensitivity, specificity, and harm related to mortality and morbidity. Sensitivity analyses and Monte Carlo simulation were performed. RESULTS The parallel threshold-based approach led to a sensitivity of 92% and a specificity of 65%. Sensitivities of the serial threshold-based approach and the branched and linear algorithms were 47%, 47%, and 74%, respectively, and the specificities were 85%, 95%, and 96%. The parallel threshold-based approach resulted in the least harm, with the serial threshold-based approach, the branched algorithm, and the linear algorithm being associated with 1.56-, 1.44-, and 1.17-times higher harm, respectively. Findings were corroborated by sensitivity and Monte Carlo analyses. CONCLUSION A threshold-based diagnostic approach is designed to find the optimal trade-off that minimizes expected harm, enhancing sensitivity and lowering specificity when appropriate, as in the given example of a symptom pointing to several life-threatening diseases. Findings-based algorithms, in contrast, solely consider clinical observations. A parallel workup, as opposed to a serial workup, additionally allows for all potential diseases to be reviewed, further reducing false negatives. The parallel threshold-based approach might, however, not be as good in other disease settings.
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Affiliation(s)
- Bettina Bisig
- Institute of Tropical Medicine, Antwerp, Belgium (BB, EB)
| | - Juan Moreira
- Institute of Tropical Medicine, Antwerp, Belgium, and Centro de Epidemiologı´a Comunitaria y Medicina Tropical, Esmeraldas, Ecuador (JM)
| | | | - Anita Asiimwe
- Centre Hospitalier Universitaire, Kigali, Rwanda (AA)
| | - Zeno Bisoffi
- Centro per le Malattie Tropicali, Negrar, Verona, Italy (ZB)
| | | | | | - Jef Van den Ende
- Institute of Tropical Medicine, University Hospital, Antwerp, Belgium (JVDE)
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Chao PW, Ou SM, Chen YT, Lee YJ, Wang FM, Liu CJ, Yang WC, Chen TJ, Chen TW, Li SY. Acute appendicitis in patients with end-stage renal disease. J Gastrointest Surg 2012; 16:1940-6. [PMID: 22777056 DOI: 10.1007/s11605-012-1961-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2012] [Accepted: 06/28/2012] [Indexed: 01/31/2023]
Abstract
BACKGROUND Acute appendicitis in patients with end-stage renal disease (ESRD) poses a diagnostic challenge. Delayed surgery can contribute to higher morbidity and mortality rates. However, few studies have evaluated this disease among ESRD patients. Our study focused on the lack of data on the incidence and risk factors of acute appendicitis among ESRD patients and compared the outcomes in patients who underwent different dialysis modalities. METHODS This national survey was conducted between 1997 and 2005 and included ESRD patients identified from the Taiwan National Health Insurance database. The incidence rate of acute appendicitis in ESRD patients was compared with that in randomly selected age-, sex-, and Charlson comorbidity score-matched non-dialysis controls. A Cox regression hazard model was used to identify risk factors. RESULTS Among 59,781 incident ESRD patients, matched one-to-one with controls, there were 328 events of acute appendicitis. The incidence rate of 16.9 per 10,000 person-years in the ESRD cohort was higher than that in the control cohort (p = 0.003). The independent risk factors were atrial fibrillation (hazard ratio [HR], 2.08), severe liver disease (HR, 1.74), diabetes mellitus (HR, 1.58), and hemodialysis (HR, 1.74). Compared with the control cohort, subsequent perforation and mortality rates of acute appendicitis were also higher in the ESRD cohorts. There was no effect of dialysis modality on the patient outcomes. CONCLUSIONS ESRD patients had a higher risk for acute appendicitis and poorer outcomes than non-dialysis populations. A careful examination of ESRD patients presenting with atypical abdominal pain to avoid misdiagnosis is extremely important to prevent delayed surgery.
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Affiliation(s)
- Pei-Wen Chao
- Department of Anesthesiology, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
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Jaspers MWM, Smeulers M, Vermeulen H, Peute LW. Effects of clinical decision-support systems on practitioner performance and patient outcomes: a synthesis of high-quality systematic review findings. J Am Med Inform Assoc 2011; 18:327-34. [PMID: 21422100 DOI: 10.1136/amiajnl-2011-000094] [Citation(s) in RCA: 310] [Impact Index Per Article: 23.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVE To synthesize the literature on clinical decision-support systems' (CDSS) impact on healthcare practitioner performance and patient outcomes. DESIGN Literature search on Medline, Embase, Inspec, Cinahl, Cochrane/Dare and analysis of high-quality systematic reviews (SRs) on CDSS in hospital settings. Two-stage inclusion procedure: (1) selection of publications on predefined inclusion criteria; (2) independent methodological assessment of preincluded SRs by the 11-item measurement tool, AMSTAR. Inclusion of SRs with AMSTAR score 9 or above. SRs were thereafter rated on level of evidence. Each stage was performed by two independent reviewers. RESULTS 17 out of 35 preincluded SRs were of high methodological quality and further analyzed. Evidence that CDSS significantly impacted practitioner performance was found in 52 out of 91 unique studies of the 16 SRs examining this effect (57%). Only 25 out of 82 unique studies of the 16 SRs reported evidence that CDSS positively impacted patient outcomes (30%). CONCLUSIONS Few studies have found any benefits on patient outcomes, though many of these have been too small in sample size or too short in time to reveal clinically important effects. There is significant evidence that CDSS can positively impact healthcare providers' performance with drug ordering and preventive care reminder systems as most clear examples. These outcomes may be explained by the fact that these types of CDSS require a minimum of patient data that are largely available before the advice is (to be) generated: at the time clinicians make the decisions.
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Affiliation(s)
- Monique W M Jaspers
- Department of Medical Informatics, Academic Medical Center, Amsterdam, The Netherlands.
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Liu JLY, Wyatt JC. The case for randomized controlled trials to assess the impact of clinical information systems. J Am Med Inform Assoc 2011; 18:173-80. [PMID: 21270132 PMCID: PMC3116250 DOI: 10.1136/jamia.2010.010306] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/19/2010] [Indexed: 01/09/2023] Open
Abstract
There is a persistent view of a significant minority in the medical informatics community that the randomized controlled trial (RCT) has a limited role to play in evaluating clinical information systems. A common reason voiced by skeptics is that these systems are fundamentally different from drug interventions, so the RCT is irrelevant. There is an urgent need to promote the use of RCTs, given the shift to evidence-based policy and the need to demonstrate cost-effectiveness of these systems. The authors suggest returning to first principles and argue that what is required is clarity about how to match methods to evaluation questions. The authors address common concerns about RCTs, and the extent to which they are fallacious, and also discuss the challenges of conducting RCTs in informatics and alternative study designs when randomized trials are infeasible. While neither a perfect nor universal evaluation method, RCTs form an important part of an evaluator's toolkit.
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Affiliation(s)
- Joseph L Y Liu
- The University of Dundee Centre for Primary Care and Population Research, Health Informatics Centre, Scottish Dental Clinical Effectiveness Programme, Dental Health Services & Research Unit, Dundee, UK.
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Abstract
The purpose of this review is to consolidate existing evidence from published systematic reviews on health information system (HIS) evaluation studies to inform HIS practice and research. Fifty reviews published during 1994-2008 were selected for meta-level synthesis. These reviews covered five areas: medication management, preventive care, health conditions, data quality, and care process/outcome. After reconciliation for duplicates, 1276 HIS studies were arrived at as the non-overlapping corpus. On the basis of a subset of 287 controlled HIS studies, there is some evidence for improved quality of care, but in varying degrees across topic areas. For instance, 31/43 (72%) controlled HIS studies had positive results using preventive care reminders, mostly through guideline adherence such as immunization and health screening. Key factors that influence HIS success included having in-house systems, developers as users, integrated decision support and benchmark practices, and addressing such contextual issues as provider knowledge and perception, incentives, and legislation/policy.
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Affiliation(s)
- Francis Lau
- School of Health Information Science, University of Victoria, Victoria, British Columbia, Canada.
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Ting HW, Wu JT, Chan CL, Lin SL, Chen MH. Decision model for acute appendicitis treatment with decision tree technology--a modification of the Alvarado scoring system. J Chin Med Assoc 2010; 73:401-6. [PMID: 20728850 DOI: 10.1016/s1726-4901(10)70087-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2009] [Accepted: 06/29/2010] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND How to decide the proper time to do laparotomies for acute appendicitis patients is sometimes very difficult, especially in areas with no imaging diagnostic tools. The Alvarado scoring system (ASS) is a convenient and inexpensive decision making tool; however, its accuracy needs to be improved. The decision tree is the most frequently used data mining technology for diagnostic model building. This study used a decision tree to modify the ASS and to prioritize the variables. METHODS We collected 532 patients who underwent appendectomy. Patients who had undergone incidental appendectomy were excluded from the study. The decision tree algorithm was constructed with the data mining workbench Clementine version 8.1. It is a top-down algorithm designed to generate a decision tree model with entropy. The algorithm chooses the best decision node with which to separate different classes from empirical data. The Wilcoxon signed rank test, Student t test and chi(2) test were used for statistical analysis. RESULTS Among the 532 patients recruited into the study, 420 had acute appendicitis and 112 had normal appendix. Women with acute appendicitis were older than their male counterparts (p < 0.001). All patients had right lower quadrant tenderness. The new model was constructed with decision tree technology, and the accuracy of the diagnostic rate was better than that of ASS (p < 0.001). The sensitivity and specificity of the new model were 0.945 and 0.805, respectively. CONCLUSION The new model is more convenient and accurate than ASS. Right lower quadrant tenderness is an inclusion criterion for acute appendicitis diagnosis. Migrating pain and neutrophil count > 75% were significant factors for acute appendicitis diagnosis if ASS score < 6. Although the criteria of nausea/vomiting and white blood cell count > 10,000/dL were significantly different between acute appendicitis and normal appendix, there was no significant contribution of entropy change below the "neutrophil count > 75%" nodes in the model. So they were erased from the decision tree model. Further studies need to be conducted to investigate why older women are at higher risk for acute appendicitis.
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Affiliation(s)
- Hsien-Wei Ting
- Department of Neurosurgery, Taipei Hospital, Department of Health, Taipei, Taiwan, R.O.C
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Abstract
BACKGROUND In view of the threat that comes with an acute abdomen, it is of major importance that diagnostics are executed quickly and efficiently. In the course of this two tendencies can be differentiated: 1) general use of complex examination (e.g. CT, MRT) of all potential patients and 2) step-by-step-diagnostics with advanced diagnostics as and when required. MATERIAL AND METHODS A total of 444 patients with an acute abdomen as admission diagnosis were investigated. All data were evaluated prospectively and analyzed retrospectively. All patients had the same basic diagnostics consisting of aclinical history, clinical examination, laboratory examination, abdominal sonography and x-ray overview images. These examinations were supplemented when required by advanced measures, such as CT, colon enema with contrast fluid, endoscopic examination and diagnostic laparotomy. RESULTS Three different disease groups of unequal diagnostic need could be identified. The first group, presented in the form of an appendicitis showed that in 80% of all patients a basic diagnosis was sufficient. Advanced examination such as CT affected 14%. The negative appendectomy rate amounted to 8%. Other diseases belonging to the first group were ileus, acute biliary diseases, perforation etc. In the second group presented in the form of a diverticulitis, an advanced radiological examination was required in 84% of all cases. Similar results are also expected in cases of pancreatitis. In the third group presented in the form of coprostasis, inflammatory etiology was found in 39% of all secondary diseases. However the symptoms became clinically apparent after treatment of the coprostasis. In this group a basic diagnosis was satisfactory in 84% of cases, however, a diagnostic laparotomy was inevitable for 3% of these patients. CONCLUSION Generally step-by-step diagnostic approach has proven itself to be efficient. For 80% of all patients it makes advanced diagnostic measures unnecessary. The exceptions are diseases in which it is necessary to know not only the diagnosis but also the disease stage. In these cases (e.g. pancreatitis, diverticulitis etc.) advanced diagnostics should be pursued from the onset. The necessity of a diagnostic laparotomy has lost importance for 1% of all patients.
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Affiliation(s)
- C W Schildberg
- Viszeral- und Allgemeinchirurgie, Universität Erlangen/Nürnberg, Deutschland.
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Wagholikar KB, Vijayraghavan S, Deshpande AW. Fuzzy Naive Bayesian model for medical diagnostic decision support. Annu Int Conf IEEE Eng Med Biol Soc 2010; 2009:3409-12. [PMID: 19963578 DOI: 10.1109/iembs.2009.5332468] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
This work relates to the development of computational algorithms to provide decision support to physicians. The authors propose a Fuzzy Naive Bayesian (FNB) model for medical diagnosis, which extends the Fuzzy Bayesian approach proposed by Okuda. A physician's interview based method is described to define a orthogonal fuzzy symptom information system, required to apply the model. For the purpose of elaboration and elicitation of characteristics, the algorithm is applied to a simple simulated dataset, and compared with conventional Naive Bayes (NB) approach. As a preliminary evaluation of FNB in real world scenario, the comparison is repeated on a real fuzzy dataset of 81 patients diagnosed with infectious diseases. The case study on simulated dataset elucidates that FNB can be optimal over NB for diagnosing patients with imprecise-fuzzy information, on account of the following characteristics - 1) it can model the information that, values of some attributes are semantically closer than values of other attributes, and 2) it offers a mechanism to temper exaggerations in patient information. Although the algorithm requires precise training data, its utility for fuzzy training data is argued for. This is supported by the case study on infectious disease dataset, which indicates optimality of FNB over NB for the infectious disease domain. Further case studies on large datasets are required to establish utility of FNB.
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Affiliation(s)
- Kavishwar B Wagholikar
- Interdisciplinary School of Scientific Computing, University of Pune, Pune-411007, India.
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Wagholikar K, Mangrulkar S, Deshpande A, Sundararajan V. Evaluation of Fuzzy Relation Method for Medical Decision Support. J Med Syst 2012; 36:233-9. [DOI: 10.1007/s10916-010-9472-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2009] [Accepted: 03/04/2010] [Indexed: 10/19/2022]
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