Wade Ros, Deng Nyanar Jasmine, Umemneku-Chikere Chinyereugo, Harden Melissa, Fulbright Helen, Hodgson Robert, Eastwood Alison, Churchill Rachel
Centre for Reviews and Dissemination, University of York, York, UK.
Health Technol Assess. 2024 Sep 4:1-53. doi: 10.3310/GRPL6978.
This work was undertaken to inform a National Institute for Health and Care Excellence guideline on the initial assessment of adults with suspected acute respiratory infection.
To undertake a rapid evidence synthesis of systematic reviews and cost-effectiveness studies of signs, symptoms and early warning scores for the initial assessment of adults with suspected acute respiratory infection.
MEDLINE, EMBASE and Cochrane Database of Systematic Reviews were searched for systematic reviews and MEDLINE, EMBASE, EconLit and National Health Service Economic Evaluation Database were searched for cost-effectiveness studies in May 2023. References of relevant studies were checked. Clinical outcomes of interest included escalation of care, antibiotic/antiviral use, time to resolution of symptoms, mortality and health-related quality of life. Risk of bias was assessed using the Risk of Bias in Systematic Reviews tool or the National Institute for Health and Care Excellence economic evaluations checklist. Results were summarised using narrative synthesis.
Nine systematic reviews and one cost-effectiveness study met eligibility criteria. Seven reviews assessed several early warning scores for patients with community- acquired pneumonia, one assessed early warning scores for nursing home-acquired pneumonia and one assessed individual signs/symptoms and the Centor score for patients with sore throat symptoms; all in face-to-face settings. Two good-quality reviews concluded that further research is needed to validate the CRB-65 in primary care/community settings. One also concluded that further research is needed on the Pneumonia Severity Index in community settings; however, the Pneumonia Severity Index requires data from tests not routinely conducted in community settings. One good-quality review concluded that National Early Warning Score appears to be useful in an emergency department/acute medical setting. One review (unclear quality) concluded that the Pneumonia Severity Index and CURB-65 appear useful in an emergency department setting. Two poor-quality reviews concluded that early warning scores can support clinical judgement and one poor-quality review found numerous problems with using early warning scores in a nursing home setting. A good-quality review concluded that individual signs and symptoms have a modest ability to diagnose streptococcal pharyngitis, and that the Centor score can enhance appropriate prescribing of antibiotics. The cost-effectiveness study assessed clinical scores and rapid antigen detection tests for sore throat, compared to delayed antibiotic prescribing. The study concluded that the clinical score is a cost-effective approach when compared to delayed prescribing and rapid antigen testing.
Several early warning scores have been evaluated in adults with suspected acute respiratory infection, mainly the CRB-65, CURB-65 and Pneumonia Severity Index in patients with community-acquired pneumonia. The evidence was insufficient to determine what triage strategies avoid serious illness. Some early warning scores (CURB-65, Pneumonia Severity Index and National Early Warning Score) appear to be useful in an emergency department/acute medical setting; however, further research is required to validate the CRB-65 and Pneumonia Severity Index in primary care/community settings. The economic evidence indicated that clinical scores may be a cost-effective approach to triage patients compared with delayed prescribing.
Only systematic reviews were eligible for inclusion in the synthesis of clinical evidence. There was a great deal of overlap in the primary studies included in the reviews, many of which had significant limitations. No studies were undertaken in remote settings (e.g. NHS 111). Only one cost-effectiveness study was identified, with limited applicability to the review question.
This article presents independent research funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme as award number NIHR159945.
开展这项工作是为了为英国国家卫生与临床优化研究所（National Institute for Health and Care Excellence）关于疑似急性呼吸道感染成人初始评估的指南提供信息。
对关于疑似急性呼吸道感染成人初始评估的体征、症状及早期预警评分的系统评价和成本效益研究进行快速证据综合分析。
于2023年5月在MEDLINE、EMBASE和Cochrane系统评价数据库中检索系统评价，并在MEDLINE、EMBASE、EconLit和英国国家医疗服务体系经济评价数据库中检索成本效益研究。对相关研究的参考文献进行了检查。感兴趣的临床结局包括护理升级、抗生素/抗病毒药物使用、症状缓解时间、死亡率及健康相关生活质量。使用《系统评价中的偏倚风险》工具或英国国家卫生与临床优化研究所经济评价清单评估偏倚风险。结果采用叙述性综合分析进行总结。
九项系统评价和一项成本效益研究符合纳入标准。七项评价评估了社区获得性肺炎患者的几种早期预警评分，一项评估了养老院获得性肺炎患者的早期预警评分，一项评估了咽痛症状患者的个体体征/症状及森托（Centor）评分；均为面对面环境下的研究。两项高质量评价得出结论，需要进一步研究以在初级保健/社区环境中验证CRB - 65。其中一项还得出结论，需要在社区环境中对肺炎严重程度指数进行进一步研究；然而，肺炎严重程度指数需要来自社区环境中非常规开展的检查的数据。一项高质量评价得出结论，国家早期预警评分在急诊科/急性内科环境中似乎有用。一项评价（质量不明）得出结论，肺炎严重程度指数和CURB - 65在急诊科环境中似乎有用。两项低质量评价得出结论，早期预警评分可支持临床判断，一项低质量评价发现养老院环境中使用早期预警评分存在诸多问题。一项高质量评价得出结论，个体体征和症状对诊断链球菌性咽炎的能力有限，且森托评分可提高抗生素的合理处方率。成本效益研究评估了咽痛的临床评分和快速抗原检测试验，并与延迟开具抗生素进行了比较。该研究得出结论，与延迟处方和快速抗原检测相比，临床评分是一种具有成本效益的方法。
已对疑似急性呼吸道感染成人的几种早期预警评分进行了评估，主要是社区获得性肺炎患者的CRB - 65、CURB - 65和肺炎严重程度指数。证据不足以确定何种分诊策略可避免严重疾病。一些早期预警评分（CURB - 65、肺炎严重程度指数和国家早期预警评分）在急诊科/急性内科环境中似乎有用；然而，需要进一步研究以在初级保健/社区环境中验证CRB - 65和肺炎严重程度指数。经济证据表明，与延迟处方相比，临床评分可能是一种具有成本效益的患者分诊方法。
只有系统评价符合纳入临床证据综合分析的条件。评价中纳入的原始研究存在大量重叠，其中许多存在重大局限性。未在偏远环境（如英国国家医疗服务体系111）开展研究。仅识别出一项成本效益研究，其对评价问题的适用性有限。
本文介绍了由英国国家卫生与临床研究机构（National Institute for Health and Care Research，NIHR）卫生技术评估项目资助的独立研究，资助编号为NIHR159945。
