engleski

Clinical decision rules are (mostly) bad, but you don’t have to be

INTRODUCTION: Clinical decision rules have become a part of standard practice in emergency departments (EDs) all over the world. Whether it is calculating the risk for pulmonary embolism (PE) with the Wells’ score, deciding on whether to image an ankle injury using the Ottawa Ankle Rule or determining whether an injured infant needs a computed tomography (CT) scan based on the PECARN Head CT Rule, clinical scores and decision rules seemingly take a complex subjective clinical decision and turn it into an objective calculation with a single correct output. Due to their widespread use, this review aims to determine if the most often used clinical decision rules and scores are supported by the literature and practice changing. METHODS: A search of the MEDLINE, Web of Science and Google Scholar was performed using the names of some of the most popular clinical decision rules and scores as search terms. Papers were included if they were randomised clinical trials (RCTs) and studied the validation, implementation or clinical impact of the decision rules. RESULTS: Most of the clinical rules studied are not externally validated and most of them are worse than the physician’s clinical judgment. Some notable examples of rules that have been studied and shown as equivalent or inferior to clinical judgment include: Alvarado score for appendicitis, Wells’ score for PE, PECARN Head CT Rule. Some rules have been shown as potentially superior to clinical judgment, such as Canadian Spine CT Rule and Ottawa Ankle Rule. CONCLUSION: Most of the clinical decision rules and scores are worse than clinical judgment and should not be a part of standard practice. Those that are better than clinical judgment should be used only in the right context the way their authors intended, and should provide a supplement to, rather than be a surrogate for proper clinical reasoning.

Clinical Decision Rules ; Clinical Reasoning ; Emergency Medicine

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