McNutt R A, Selker H P
Department of Medicine, New England Medical Center, Boston, Massachusetts.
Med Decis Making. 1988 Apr-Jun;8(2):90-4. doi: 10.1177/0272989X8800800204.
The use of the acute ischemic heart disease predictive instrument reduced coronary care unit (CCU) admissions for patients without acute ischemic heart disease by 30%. One hypothesis holds that it reinforced physicians' correctly low estimates of the probability of acute ischemia, supporting a decision against CCU admission, another that it lowered physicians' over-high probability estimates for acute ischemia so that CCU admission was felt to be unnecessary. The authors asked 86 physicians to estimate the probability of acute ischemia for each of three study cases and to decide on CCU admission. For the low-probability case, the mean of physicians' probability estimates for acute ischemia was 46%, vs. the predictive instrument's calculated probability of 19% (p less than 0.00001), a 142% over-estimation by the physicians. For the medium-probability case, the mean of physicians' estimates was 54%, vs. the calculated probability of 58% (not significant). For the high-probability case, the mean of physicians' estimates was 82%, vs. the calculated probability of 78% (not significant). All cases for which physicians considered not admitting to the CCU corresponded to their probability estimates of acute ischemia's being in a threshold range of approximately 10 to 30%. These results support the hypothesis that the mechanism by which the predictive instrument reduces unnecessary CCU admissions is by downward correction of physicians' overly-high suspicions of acute cardiac ischemia into a threshold range for which CCU admission is considered unnecessary.
急性缺血性心脏病预测工具的使用使非急性缺血性心脏病患者的冠心病监护病房（CCU）入院率降低了30%。一种假说认为，它强化了医生对急性缺血可能性正确的低估计，支持了不将患者收入CCU的决定；另一种假说认为，它降低了医生对急性缺血过高的可能性估计，从而使人觉得没有必要将患者收入CCU。作者让86名医生对三个研究病例分别估计急性缺血的可能性，并决定是否将患者收入CCU。对于低可能性病例，医生对急性缺血可能性估计的平均值为46%，而预测工具计算出的可能性为19%（p<0.00001），医生高估了142%。对于中等可能性病例，医生估计的平均值为54%，而计算出的可能性为58%（无显著差异）。对于高可能性病例，医生估计的平均值为82%，而计算出的可能性为78%（无显著差异）。医生认为不应收入CCU的所有病例，其急性缺血可能性估计都在大约10%至30%的阈值范围内。这些结果支持了这样一种假说，即预测工具减少不必要的CCU入院的机制是将医生对急性心脏缺血过度高的怀疑向下校正到一个认为不需要收入CCU的阈值范围。
