Clinician Gestalt Estimate of Pretest Probability for Acute Coronary Syndrome and Pulmonary Embolism in Patients With Chest Pain and Dyspnea
- 1 March 2014
- journal article
- clinical trial
- Published by Elsevier BV in Annals of Emergency Medicine
- Vol. 63 (3), 275-280
- https://doi.org/10.1016/j.annemergmed.2013.08.023
Abstract
Pretest probability helps guide diagnostic testing for patients with suspected acute coronary syndrome and pulmonary embolism. Pretest probability derived from the clinician's unstructured gestalt estimate is easier and more readily available than methods that require computation. We compare the diagnostic accuracy of physician gestalt estimate for the pretest probability of acute coronary syndrome and pulmonary embolism with a validated, computerized method. This was a secondary analysis of a prospectively collected, multicenter study. Patients (N=840) had chest pain, dyspnea, nondiagnostic ECGs, and no obvious diagnosis. Clinician gestalt pretest probability for both acute coronary syndrome and pulmonary embolism was assessed by visual analog scale and from the method of attribute matching using a Web-based computer program. Patients were followed for outcomes at 90 days. Clinicians had significantly higher estimates than attribute matching for both acute coronary syndrome (17% versus 4%; P<.001, paired t test) and pulmonary embolism (12% versus 6%; P<.001). The 2 methods had poor correlation for both acute coronary syndrome (r(2)=0.15) and pulmonary embolism (r(2)=0.06). Areas under the receiver operating characteristic curve were lower for clinician estimate compared with the computerized method for acute coronary syndrome: 0.64 (95% confidence interval [CI] 0.51 to 0.77) for clinician gestalt versus 0.78 (95% CI 0.71 to 0.85) for attribute matching. For pulmonary embolism, these values were 0.81 (95% CI 0.79 to 0.92) for clinician gestalt and 0.84 (95% CI 0.76 to 0.93) for attribute matching. Compared with a validated machine-based method, clinicians consistently overestimated pretest probability but on receiver operating curve analysis were as accurate for pulmonary embolism but not acute coronary syndrome.Keywords
This publication has 26 references indexed in Scilit:
- The Chest Pain Choice Decision Aid A Randomized TrialCirculation: Cardiovascular Quality and Outcomes, 2012
- Variation in Cardiologists’ Propensity to Test and TreatCirculation: Cardiovascular Quality and Outcomes, 2010
- 12-Lead ECG Findings of Pulmonary Hypertension Occur More Frequently in Emergency Department Patients With Pulmonary Embolism Than in Patients Without Pulmonary EmbolismAnnals of Emergency Medicine, 2010
- Accuracy of Very Low Pretest Probability Estimates for Pulmonary Embolism Using the Method of Attribute Matching Compared with the Wells ScoreAcademic Emergency Medicine, 2010
- Randomized Trial of Computerized Quantitative Pretest Probability in Low-Risk Chest Pain Patients: Effect on Safety and Resource UseAnnals of Emergency Medicine, 2009
- Assessment of pretest probability of pulmonary embolism in the emergency department by physicians in training using the Wells modelThrombosis Research, 2007
- Emergency Medicine Practitioner Knowledge and Use of Decision Rules for the Evaluation of Patients with Suspected Pulmonary Embolism: Variations by Practice Setting and Training LevelAcademic Emergency Medicine, 2007
- Prospective Multicenter Study of Quantitative Pretest Probability Assessment to Exclude Acute Coronary Syndrome for Patients Evaluated in Emergency Department Chest Pain UnitsAnnals of Emergency Medicine, 2006
- Emergency Physicians' Fear of Malpractice in Evaluating Patients With Possible Acute Cardiac IschemiaAnnals of Emergency Medicine, 2005
- Defensive Medicine Among High-Risk Specialist Physicians in a Volatile Malpractice EnvironmentJAMA, 2005