Terminology: Is it just semantics?

1. Terminology: Is it just semantics? Grant Dex

2. What are Clinical Prediction Rules/Guides? • clinical tools that quantify the contribution of the history, physical examination and diagnostic tests and stratify patients according to the probability of having a target disorder

3. Commonly used terms: • Clinical decision aid • Clinical decision guide • Clinical prediction guide • Clinical prediction rule • Clinical decision rule • Clinical prediction tool • Clinical decision tool

4. Semantics? • Does it matter what term we use? • Do they mean the same thing? • Can they be used interchangeably? • Is clinical prediction the same as clinical decision-making?

5. Semantics? • Is a “Rule” the same as a “Guide” or “Tool” • Different terminology for different situations (diagnosis, prognosis)? • But, is there a single GENERIC term we can use?

6. Which would you choose? Clinical - • decision aid • decision guide • prediction guide • prediction rule • decision rule • prediction tool • decision tool

7. Use of terms in the literature- Precedents • Clinical prediction rules. Applications and methodological standards: JH Wasson et al- NEJM, 1985 • Clinical prediction rules. A review and suggested modifications of methodological standards: A Laupacis, - JAMA, 1997 - Am Med Assoc

8. Diagnostic prediction rules: principles, requirements and pitfalls. JA Knottnerus - Primary care, 1995 • Users' guides to the medical literature: XXII: how to use articles about clinical decision rules. TG McGinn, GH Guyatt, PC Wyer, CD Naylor, IG - JAMA, 2000 - Am Med Assoc

9. Understanding articles describing  clinical prediction toolsAG Randolph, GH Guyatt, JE Calvin, G Doig - Critical care medicine, 1998 • Evidence-based diagnosis: a handbook of clinical prediction rules By Mark H. Ebell

10. Diagnosis of left ventricular systolic dysfunction (LVSD): development and validation of a clinical prediction rule in primary care. T Fahey, FM Sullivan et al - Family Practice, 2007 • PubMed Clinical Queries • “clinical prediction guides” Haynes et al

11. PubMed Search [All Fields] • "clinical prediction guide" Results: 9 • "clinical prediction tool" Results: 10 • "clinical decision rule" Results: 151 • "clinical prediction rule" Results: 232

12. What do GPs & others think? • Glasgow RCGP Conference: • 76/100 chose Clinical Prediction GUIDE • Notts Division of Primary Care: • Researchers - Clinical Prediction Rule 24/24 • Clinical Lecturers/Teaching Fellows Clinical Prediction GUIDE 27/33 ~ 82% Different perspectives?

13. Doodle Poll – 60 responses Clinical decision aid - 10 Clinical decision guide - 2 Clinical prediction guide - 26 Clinical prediction rule – 19 Clinical decision rule - 3

14. Doodle comments • “I prefer clinical decision aid (or guide) as these tools aid in the decision making process but the final decision should be a clinical one as actual patients should be treated as individuals.”

15. Doodle Comments “I am uncomfortable with the use of "rule" - Its connotations are that there is no option to "disobey" even if it is going to benefit/harm a patient.” • “I'd opt for CPG because its: prediction not decision and a guide not a rule.”

16. Further comments “I use clinical prediction rule if it estimates probability of diagnosis or prognosis. I think clinical decision rule if the probability estimate is then linked explicitly to a management recommendation. So I view cardiovascular risk functions such as Framingham, Qrisk etc at prognostic clinical prediction rules, whilst the Ottawa ankle rule is a clinical decision rule because of advice about whether or not to x ray ankle”

17. So... Discussion! • Is it important what terms we use? • Decision vs. Prediction • Clinical context • Rule vs. Guide • What Generic term?