急诊医师整体判断预测 5 至 20 岁患者急性阑尾炎的诊断性能。
Diagnostic Performance of Emergency Physician Gestalt for Predicting Acute Appendicitis in Patients Age 5 to 20 Years.
机构信息
Division of Research, Kaiser Permanente, Oakland, CA.
University of California San Diego School of Medicine, La Jolla, CA.
出版信息
Acad Emerg Med. 2020 Sep;27(9):821-831. doi: 10.1111/acem.13931. Epub 2020 Apr 2.
OBJECTIVES
Pediatric appendicitis remains a challenging diagnosis in the emergency department (ED). Available risk prediction algorithms may contribute to excessive ED imaging studies. Incorporation of physician gestalt assessment could help refine predictive tools and improve diagnostic imaging decisions.
METHODS
This study was a subanalysis of a parent study that prospectively enrolled patients ages 5 to 20.9 years with a chief complaint of abdominal pain presenting to 11 community EDs within an integrated delivery system between October 1, 2016, and September 30, 2018. Prior to diagnostic imaging, attending emergency physicians enrolled patients with ≤5 days of right-sided or diffuse abdominal pain using a Web-based application embedded in the electronic health record. Predicted risk (gestalt) of acute appendicitis was prospectively entered using a sliding scale from 1% to 100%. As a planned secondary analysis, we assessed the performance of gestalt via c-statistics of receiver operating characteristic (ROC) curves; tested associations between gestalt performance and patient, physician, and facility characteristics; and examined clinical characteristics affecting gestalt estimates.
RESULTS
Of 3,426 patients, 334 (9.8%) had confirmed appendicitis. Physician gestalt had excellent ROC curve characteristics (c-statistic = 0.83, 95% confidence interval = 0.81 to 0.85), performing particularly well in the low-risk strata (appendicitis rate = 1.1% in gestalt 1%-10% range, negative predictive value of 98.9% for appendicitis diagnosis). Physicians with ≥5 years since medical school graduation demonstrated improved gestalt performance over those with less experience (p = 0.007). All clinical characteristics tested, except pain <24 hours, were significantly associated with physician gestalt value (p < 0.05).
CONCLUSION
Physician gestalt for acute appendicitis diagnosis performed well, especially in low-risk patients and when employed by experienced physicians.
目的
儿科阑尾炎仍然是急诊科（ED）具有挑战性的诊断。现有的风险预测算法可能会导致过多的 ED 影像学研究。纳入医生的整体评估可能有助于完善预测工具并改善诊断性影像学决策。
方法
本研究是一项前瞻性研究的子分析，该研究纳入了 2016 年 10 月 1 日至 2018 年 9 月 30 日期间在一个综合医疗系统内的 11 个社区急诊室就诊的年龄在 5 至 20.9 岁，以腹痛为主诉的患者。在进行诊断性影像学检查之前，主治急诊医师使用嵌入电子病历的基于网络的应用程序对≤5 天出现右侧或弥漫性腹痛的患者进行登记。前瞻性地使用从 1%到 100%的滑动比例输入急性阑尾炎的预测风险（整体评估）。作为计划中的二次分析，我们通过接受者操作特征（ROC）曲线的 C 统计量评估整体评估的性能；检验整体评估表现与患者、医生和医疗机构特征之间的关联；并检查影响整体评估的临床特征。
结果
在 3426 名患者中，有 334 名（9.8%）患者确诊为阑尾炎。医生的整体评估具有出色的 ROC 曲线特征（C 统计量=0.83，95%置信区间=0.81 至 0.85），在低风险人群中表现尤为出色（整体评估 1%-10%范围的阑尾炎发生率为 1.1%，阑尾炎诊断的阴性预测值为 98.9%）。毕业≥5 年的医生比经验较少的医生的整体评估表现更好（p=0.007）。除疼痛时间<24 小时外，所有测试的临床特征均与医生的整体评估值显著相关（p<0.05）。
结论
急性阑尾炎诊断的医生整体评估表现良好，尤其是在低风险患者中，且经验丰富的医生应用效果更佳。
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