Dataset Information

A systematic review of clinical prediction rules for the diagnosis of chronic heart failure.

ABSTRACT:

Aims

This study sought to review the literature for clinical prediction models for the diagnosis of patients with chronic heart failure in the community and to validate the models in a novel cohort of patients with a suspected diagnosis of chronic heart failure.

Methods and results

MEDLINE and Embase were searched from 1946 to Q4 2017. Studies were eligible if they contained at least one multivariable model for the diagnosis of chronic heart failure applicable to the primary care setting. The CHARMS checklist was used to evaluate models. We also validated models, where possible, in a novel cohort of patients with a suspected diagnosis of heart failure referred to a rapid access diagnostic clinic. In total, 5310 articles were identified with nine articles subsequently meeting the eligibility criteria. Three models had undergone internal validation, and four had undergone external validation. No clinical impact studies have been completed to date. Area under the curve (AUC) varied from 0.74 to 0.93 and from 0.60 to 0.65 in the novel cohort for clinical models alone with AUC up to 0.89 in combination with electrocardiogram and B-type natriuretic peptide (BNP). The AUC for BNP was 0.86 (95% confidence interval 83.3-88.6%).

Conclusions

This review demonstrates that there are a number of clinical prediction rules relevant to the diagnosis of chronic heart failure in the literature. Clinical impact studies are required to compare the use of clinical prediction rules and biomarker strategies in this setting.

SUBMITTER: Gallagher J

PROVIDER: S-EPMC6487728 | biostudies-literature | 2019 Jun

REPOSITORIES: biostudies-literature

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Publications

A systematic review of clinical prediction rules for the diagnosis of chronic heart failure.

Gallagher Joe J McCormack Darren D Zhou Shuaiwei S Ryan Fiona F Watson Chris C McDonald Kenneth K Ledwidge Mark T MT

ESC heart failure 20190310 3

<h4>Aims</h4>This study sought to review the literature for clinical prediction models for the diagnosis of patients with chronic heart failure in the community and to validate the models in a novel cohort of patients with a suspected diagnosis of chronic heart failure.<h4>Methods and results</h4>MEDLINE and Embase were searched from 1946 to Q4 2017. Studies were eligible if they contained at least one multivariable model for the diagnosis of chronic heart failure applicable to the primary care ...[more]

PMID: 30854781

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Project description: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.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.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.

Project description:BACKGROUND: Evidence-based guidelines have the potential to improve healthcare. However, their de-novo-development requires substantial resources -- especially for complex conditions, and adaptation may be biased by contextually influenced recommendations in source guidelines. In this paper we describe a new approach to guideline development -- the systematic guideline review method (SGR), and its application in the development of an evidence-based guideline for family physicians on chronic heart failure (CHF). METHODS: A systematic search for guidelines was carried out. Evidence-based guidelines on CHF management in adults in ambulatory care published in English or German between the years 2000 and 2004 were included. Guidelines on acute or right heart failure were excluded. Eligibility was assessed by two reviewers, methodological quality of selected guidelines was appraised using the AGREE instrument, and a framework of relevant clinical questions for diagnostics and treatment was derived. Data were extracted into evidence tables, systematically compared by means of a consistency analysis and synthesized in a preliminary draft. Most relevant primary sources were re-assessed to verify the cited evidence. Evidence and recommendations were summarized in a draft guideline. RESULTS: Of 16 included guidelines five were of good quality. A total of 35 recommendations were systematically compared: 25/35 were consistent, 9/35 inconsistent, and 1/35 un-rateable (derived from a single guideline). Of the 25 consistencies, 14 were based on consensus, seven on evidence and four differed in grading. Major inconsistencies were found in 3/9 of the inconsistent recommendations. We re-evaluated the evidence for 17 recommendations (evidence-based, differing evidence levels and minor inconsistencies) - the majority was congruent. Incongruity was found where the stated evidence could not be verified in the cited primary sources, or where the evaluation in the source guidelines focused on treatment benefits and underestimated the risks. The draft guideline was completed in 8.5 man-months. The main limitation to this study was the lack of a second reviewer. CONCLUSION: The systematic guideline review including framework development, consistency analysis and validation is an effective, valid, and resource saving-approach to the development of evidence-based guidelines.

Project description:BackgroundThe efficacy of statin therapy in patients with established chronic heart failure (CHF) is a subject of much debate.Methods and findingsWe conducted three systematic literature searches to assess the evidence supporting the prescription of statins in CHF. First, we investigated the participation of CHF patients in randomized placebo-controlled clinical trials designed to evaluate the efficacy of statins in reducing major cardiovascular events and mortality. Second, we assessed the association between serum cholesterol and outcome in CHF. Finally, we evaluated the ability of statin treatment to modify surrogate endpoint parameters in CHF. Using validated search strategies, we systematically searched PubMed for our three queries. In addition, we searched the reference lists from eligible studies, used the "see related articles" feature for key publications in PubMed, consulted the Cochrane Library, and searched the ISI Web of Knowledge for papers citing key publications. Search 1 resulted in the retrieval of 47 placebo-controlled clinical statin trials involving more than 100,000 patients. CHF patients had, however, been systematically excluded from these trials. Search 2 resulted in the retrieval of eight studies assessing the relationship between cholesterol levels and outcome in CHF patients. Lower serum cholesterol was consistently associated with increased mortality. Search 3 resulted in the retrieval of 18 studies on the efficacy of statin treatment in CHF. On the whole, these studies reported favorable outcomes for almost all surrogate endpoints.ConclusionsSince CHF patients have been systematically excluded from randomized, controlled clinical cholesterol-lowering trials, the effect of statin therapy in these patients remains to be established. Currently, two large, randomized, placebo-controlled statin trials are under way to evaluate the efficacy of statin treatment in terms of reducing clinical endpoints in CHF patients in particular.

Project description:BackgroundDiagnostic 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.MethodsWe 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.ResultsTwenty-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).ConclusionThere 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 registrationThe 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.

Dataset Information

A systematic review of clinical prediction rules for the diagnosis of chronic heart failure.

Aims

Methods and results

Conclusions

Publications

A systematic review of clinical prediction rules for the diagnosis of chronic heart failure.

Similar Datasets

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