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HRB Centre for Primary Care Research Department of General Practice. Royal College of Surgeons in Ireland. Predicting severity of pneumonia in general practice: a meta-analysis of the CRB-65 criteria. Maggie McNally, James Curtain, Kirsty O’Brien, Borislav D Dimitrov, and Tom Fahey. Outline.

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Maggie McNally, James Curtain, Kirsty O’Brien, Borislav D Dimitrov, and Tom Fahey

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Maggie mcnally james curtain kirsty o brien borislav d dimitrov and tom fahey

HRB Centre for Primary Care Research

Department of General Practice

Royal College of Surgeons in Ireland

Predicting severity of pneumonia in general practice: a meta-analysis of the CRB-65 criteria

Maggie McNally, James Curtain, Kirsty O’Brien, Borislav D Dimitrov, and Tom Fahey


Outline

Outline

  • What is a clinical prediction rule?

  • Assessment of clinical prediction rules

  • CRB-65: a clinical prediction rule

  • Statistical methods in meta-analysis

  • Results

  • Conclusions

  • Future work


Clinical prediction rule

Clinical Prediction Rule

  • Clinical tool that quantifies contribution of:

    • History

    • Examination

    • Diagnostic tests

  • Stratify patients according to probability of having target disorder

  • Outcome can be in terms of diagnosis, prognosis, referral or treatment


Ottawa ankle rule an example of a cpr

Ottawa Ankle Rule: an example of a CPR


Stages of assessment of a clinical prediction rule

Stages of assessment of a Clinical Prediction Rule

Step 1: Derivation

identification of factors with predictive power

Step 2: Validation

evidence of reproducible accuracy

Narrow Broad

Step 3: Impact Analysis

evidence of rule changing behaviour and improving outcome

Level of Evidence

4

3

2

1


Crb 65 a clinical prediction rule

CRB-65: a clinical prediction rule

Confusion

Respiratory rate ≥ 30/min

Blood pressure (SBP≤ 90 or DBP≤60)

Age ≥ 65

1 or 2

0

3 or 4

Low Risk

mortality 1.2%

Intermediate Risk

mortality 8.13%

High Risk

mortality 31%

Likely suitable for home treatment

Consider hospital referral

Urgent hospital admission


Studies included in meta analysis n 13

Studies included in meta-analysis (n=13)


Level of evidence for crb 65

Level of evidence for CRB-65

Step 1: Derivation

identification of factors with predictive power

Step 2: Validation

evidence of reproducible accuracy

Narrow Broad

Step 3: Impact Analysis

evidence of rule changing behaviour and improving outcome

Level of Evidence

4

3

2

1


Statistical methods

Statistical Methods

  • Derivation study used as predictive model

  • Results presented as ratio measurement:

    predicted deaths by CRB-65 rule

    observed deaths in validation study


Results

Results


Crb 65

CRB-65

Confusion

Respiratory rate ≥ 30/min

Blood pressure (SBP≤ 90 or DBP≤60)

Age ≥ 65

0

1 or 2

3 or 4

Low Risk

mortality 1.2%

Intermediate Risk

mortality 8.13%

High Risk

mortality 31%


Maggie mcnally james curtain kirsty o brien borislav d dimitrov and tom fahey

n = 799

events = 0 (0%)

RR 9.63 (CI 1.23 – 75.63)

n = 1887

events = 14 (0.74%)

RR 1.25 (CI 0.60 – 2.59)


Crb 651

CRB-65

Confusion

Respiratory rate ≥ 30/min

Blood pressure (SBP≤ 90 or DBP≤60)

Age ≥ 65

0

1 or 2

3 or 4

Low Risk

mortality 1.2%

Intermediate Risk

mortality 8.13%

High Risk

mortality 31%


Maggie mcnally james curtain kirsty o brien borislav d dimitrov and tom fahey

n = 647

events = 10 (1.5%)

RR 4.92 (CI 2.39 – 10.11)

n = 5674

events = 455 (8.0%)

RR 0.99 (CI 0.80 – 1.23)


Crb 652

CRB-65

Confusion

Respiratory rate ≥ 30/min

Blood pressure (SBP≤ 90 or DBP≤60)

Age ≥ 65

0

1 or 2

3 or 4

Low Risk

mortality 1.2%

Intermediate Risk

mortality 8.13%

High Risk

mortality 31%


Maggie mcnally james curtain kirsty o brien borislav d dimitrov and tom fahey

n = 26

events = 5 (19.2%)

RR 1.58 (CI 0.59 – 4.19)

n = 869

events = 257 (29.6%)

RR 1.04 (CI 0.88 – 1.23)


Conclusions

Conclusions


Hospital based patients

Hospital Based Patients

Confusion

Respiratory rate ≥ 30/min

Blood pressure (SBP≤ 90 or DBP≤60)

Age ≥ 65

0

1 or 2

3 or 4

Low Risk

mortality 1.2%

Intermediate Risk

mortality 8.13%

High Risk

mortality 31%


Community based patients

Community Based Patients

  • General trend towards over-prediction

  • However,

    • Low cohort numbers

    • Low event numbers


Future work

Future Work

Step 1: Derivation

identification of factors with predictive power

Step 2: Validation

evidence of reproducible accuracy

Narrow Broad

Step 3: Impact Analysis

evidence of rule changing behaviour and improving outcome

Level of Evidence

4

3

2

1


Acknowledgements

Acknowledgements

  • RCSI Research Institute

  • Grainne McCabe, RCSI Library


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