in EM we love clinical decision tools, risk stratification tools. HEART, Canadian (___), Wells, PERC, Ottawa (__)...but, what do we really know about them? a short thread from the talk (1/) https://twitter.com/BaystateEM/status/1297904123216564225
Know if it's a 1-way tool or a 2-way tool? A 2-way tool is a bit easier to use b/c it tells you when to act and when not to (i.e. scan or don't scan - Canadian head/c-spine, Ottawa ankle etc). 1-way tools tell you - if negative, don't do X.. but...it's tempting to use as 2-way
Know if it's a 1-way tool or a 2-way tool? A 2-way tool is a bit easier to use b/c it tells you when to act and when not to (i.e. scan or don't scan - Canadian head/c-spine, Ottawa ankle etc). 1-way tools tell you - if negative, don't do X.. but...it's tempting to use as 2-way
Know if it's a 1-way tool or a 2-way tool? A 2-way tool is a bit easier to use b/c it tells you when to act and when not to (i.e. scan or don't scan - Canadian head/c-spine, Ottawa ankle etc). 1-way tools tell you - if negative, don't do X.. but...it's tempting to use as 2-way
It's helpful to know *how* the tool was derived. How were the variables determined? Inclusion and exclusion criteria are also important (can help avoid indication creep & ensure right patient population) - eg. Canadian head CT often applied to trivial injury
It's helpful to know *how* the tool was derived. How were the variables determined? Inclusion and exclusion criteria are also important (can help avoid indication creep & ensure right patient population) - eg. Canadian head CT often applied to trivial injury
It's helpful to know *how* the tool was derived. How were the variables determined? Inclusion and exclusion criteria are also important (can help avoid indication creep & ensure right patient population) - eg. Canadian head CT often applied to trivial injury
Has the tool been validated? Where? How (ideally prospectively)? This is important because you want to make sure it 'works', especially outside of a single population and by various clinicians
What is the impact of the clinical decision tool? Has an impact analysis been done? These tools may perform well in different environments (eg. imaging tools may actually *increase* ordering in places outside the US or places that don't have wild overtesting issues)
What is the impact of the clinical decision tool? Has an impact analysis been done? These tools may perform well in different environments (eg. imaging tools may actually *increase* ordering in places outside the US or places that don't have wild overtesting issues)
What is the impact of the clinical decision tool? Has an impact analysis been done? These tools may perform well in different environments (eg. imaging tools may actually *increase* ordering in places outside the US or places that don't have wild overtesting issues)
Of course, the biggest thing is...does the tool add value over gestalt? This will very much depend on the clinician and local milieu. People love to cite https://pubmed.ncbi.nlm.nih.gov/28238497/  as "proof that my gestalt is just as good"...but a lot of this depends on *what* you're measuring
Structured Clinical Decision Aids Are Seldom Compared With Subjective Physician Judgment, and Are...

Physician judgment is infrequently assessed when the performance of an aid for decisionmaking is evaluated, and, when reported, the decision aid seldom outperformed physician judgment.

https://pubmed.ncbi.nlm.nih.gov/28238497/
Are you measuring probability of PE? Or are you measuring if (and how) clinicians evaluate for PE (the action that actually reaches the patient)? This meta-analysis found ↑ CT yield (kind of a proxy for appropriate ordering) with decision tools https://pubmed.ncbi.nlm.nih.gov/26747217/ 
The Impact of Clinical Decision Rules on Computed Tomography Use and Yield for Pulmonary Embolism:...

Among participants with suspected pulmonary embolism, implementation of the Wells criteria was associated with a modest increase in CT angiography yield. There is a lack of cluster-randomized trials...

https://pubmed.ncbi.nlm.nih.gov/26747217/
Despite being ubiquitous & amazing resources to help us use them, clinicians misuse and misinterpret these toools https://pubmed.ncbi.nlm.nih.gov/32220127/  So..when you use a decision tool,know how you're supposed to use it, look it up (everytime...) & think about why you're using it/added value
Provider Perspectives on the Use of Evidence-based Risk Stratification Tools in the Evaluation of...

This exploration of the use of risk stratification tools in the evaluation of PE found that barriers to use primarily exist at the provider level, whereas facilitators to the use of these tools are...

https://pubmed.ncbi.nlm.nih.gov/32220127/
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