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Maggie McNally, James Curtain, Kirsty O’Brien, Borislav D Dimitrov, and Tom Fahey HRB Centre for Primary Care Research Department of General Practice Royal.

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Presentation on theme: "Maggie McNally, James Curtain, Kirsty O’Brien, Borislav D Dimitrov, and Tom Fahey HRB Centre for Primary Care Research Department of General Practice Royal."— Presentation transcript:

1 Maggie McNally, James Curtain, Kirsty O’Brien, Borislav D Dimitrov, and Tom Fahey HRB Centre for Primary Care Research Department of General Practice Royal College of Surgeons in Ireland Predicting severity of pneumonia in general practice: a meta- analysis of the CRB-65 criteria

2 Outline What is a clinical prediction rule? Assessment of clinical prediction rules CRB-65: a clinical prediction rule Statistical methods in meta-analysis Results Conclusions Future work

3 Clinical Prediction Rule Clinical tool that quantifies contribution of: –History –Examination –Diagnostic tests Stratify patients according to probability of having target disorder Outcome can be in terms of diagnosis, prognosis, referral or treatment

4 Ottawa Ankle Rule: an example of a CPR

5 Stages of assessment of a Clinical Prediction Rule Step 1: Derivation identification of factors with predictive power Step 2: Validation evidence of reproducible accuracy Narrow Broad Step 3: Impact Analysis evidence of rule changing behaviour and improving outcome Level of Evidence 4321

6 Confusion Respiratory rate ≥ 30/min Blood pressure (SBP≤ 90 or DBP≤60) Age ≥ 65 0 1 or 2 3 or 4 Low Risk mortality 1.2% Intermediate Risk mortality 8.13% High Risk mortality 31% CRB-65: a clinical prediction rule Likely suitable for home treatment Consider hospital referral Urgent hospital admission

7 Studies included in meta-analysis (n=13) studysettingparticipants Barlow et al 2007inpatients419 Bauer et al 2006outpatients + inpatients1959 Bont et al 2008outpatients314 Buising et al 2007emergency department740 Capelastegui et al 2006outpatients + inpatients1776 Chalmers et al 2008inpatients1007 Kruger et al 2008inpatients1404 Man et al 2007inpatients1016 Menendez et al 2009inpatients447 Myint et al 2006inpatients192 Schaaf et al 2007inpatients105 Schuetz et al 2008emergency department373 Zuberi et al 2008inpatients137 TOTAL9889

8 Level of evidence for CRB-65 Step 1: Derivation identification of factors with predictive power Step 2: Validation evidence of reproducible accuracy Narrow Broad Step 3: Impact Analysis evidence of rule changing behaviour and improving outcome Level of Evidence 4321

9 Statistical Methods Derivation study used as predictive model Results presented as ratio measurement: predicted deaths by CRB-65 rule observed deaths in validation study

10 Results

11 Confusion Respiratory rate ≥ 30/min Blood pressure (SBP≤ 90 or DBP≤60) Age ≥ 65 01 or 2 3 or 4 Low Risk mortality 1.2% Intermediate Risk mortality 8.13% High Risk mortality 31% CRB-65

12 RR 1.25 (CI 0.60 – 2.59) RR 9.63 (CI 1.23 – 75.63) n = 799 events = 0 (0%) n = 1887 events = 14 (0.74%)

13 Confusion Respiratory rate ≥ 30/min Blood pressure (SBP≤ 90 or DBP≤60) Age ≥ 65 01 or 2 3 or 4 Low Risk mortality 1.2% Intermediate Risk mortality 8.13% High Risk mortality 31% CRB-65

14 n = 647 events = 10 (1.5%) n = 5674 events = 455 (8.0%) RR 4.92 (CI 2.39 – 10.11) RR 0.99 (CI 0.80 – 1.23)

15 Confusion Respiratory rate ≥ 30/min Blood pressure (SBP≤ 90 or DBP≤60) Age ≥ 65 01 or 2 3 or 4 Low Risk mortality 1.2% Intermediate Risk mortality 8.13% High Risk mortality 31% CRB-65

16 n = 26 events = 5 (19.2%) n = 869 events = 257 (29.6%) RR 1.58 (CI 0.59 – 4.19) RR 1.04 (CI 0.88 – 1.23)

17 Conclusions

18 Confusion Respiratory rate ≥ 30/min Blood pressure (SBP≤ 90 or DBP≤60) Age ≥ 65 01 or 2 3 or 4 Low Risk mortality 1.2% Intermediate Risk mortality 8.13% High Risk mortality 31% Hospital Based Patients

19 Community Based Patients General trend towards over-prediction However, –Low cohort numbers –Low event numbers

20 Future Work Step 1: Derivation identification of factors with predictive power Step 2: Validation evidence of reproducible accuracy Narrow Broad Step 3: Impact Analysis evidence of rule changing behaviour and improving outcome Level of Evidence 4321

21 Acknowledgements RCSI Research Institute Grainne McCabe, RCSI Library


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