Clinical uncertainty, diagnostic accuracy, and outcomes in emergency department patients presenting with dyspnea
Clinical uncertainty, diagnostic accuracy, and outcomes in emergency department patients presenting with dyspnea
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DOI：
10.1001/archinte.168.7.741
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发表时间：
2008-04-14
影响因子：
--
通讯作者：
Januzzi, James L., Jr.
中科院分区：
文献类型：
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作者：
Green, Sandy M.;Martinez-Rumayor, Abelardo;Januzzi, James L., Jr.
背景：呼吸困难是急诊科(ED)常见的主诉，可能是诊断的一个挑战。我们假设，在这种情况下，诊断的不确定性与不良结局相关，氨基末端前-B型利钠肽(NT-proBNP)检测将提高诊断准确性，减少诊断不确定性。方法：从急诊科呼吸困难调查(PROID)研究中对592名呼吸困难患者进行评估。管理医生被要求提供从0%到100%的急性不稳定型心力衰竭(ADHF)的可能性估计。20%或更低或80%或更高的确定性估计被归类为临床确定性，而21%至79%之间的估计被定义为临床不确定性。研究了临床不确定性、住院时间、发病率和死亡率之间的关系。结果：185例患者(31%)存在临床不确定性，其中103例(56%)有ADHF。根据临床不确定性判断的患者住院时间更长，发病率和死亡率更高，尤其是ADHF患者。临床判断的受试者操作特征分析得出临床确定性组的曲线下面积(AUC)为0.88，不确定组为0.76(P
Background: Dyspnea is a common complaint in the emergency department (ED) and may be a diagnostic challenge. We hypothesized that diagnostic uncertainty in this setting is associated with adverse outcomes, and amino-terminal pro-B-type natriuretic peptide (NT-proBNP) testing would improve diagnostic accuracy and reduce diagnostic uncertainty.Methods: A total of 592 dyspneic patients were evaluated from the ProBNP Investigation of Dyspnea in the Emergency Department (PRIDE) study. Managing physicians were asked to provide estimates from 0% to 100% of the likelihood of acutely destabilized heart failure (ADHF). A certainty estimate of either 20% or lower or 80% or higher was classified as clinical certainty, while estimates between 21% and 79% were defined as clinical uncertainty. Associations between clinical uncertainty, hospital length of stay, morbidity, and mortality were examined. The diagnostic value of clinical judgment vs NT-proBNP measurement was compared across categories of clinical certainty.Results: Clinical uncertainty was present in 185 patients (31%), 103 (56%) of whom had ADHF. Patients judged with clinical uncertainty had longer hospital length of stay and increased morbidity and mortality, especially those with ADHF. Receiver operating characteristic analysis of clinical judgment yielded an area under the curve (AUC) of 0.88 in the clinical certainty group and 0.76 in the uncertainty group (P