Developing an International Register of Clinical Prediction Rules for Use in Primary Care: A Descriptive Analysis

Claire Keogh; Emma Wallace; Kirsty K. O’Brien; Rose Galvin; Susan M. Smith; Cliona Lewis; Anthony Cummins; Grainne Cousins; Borislav D. Dimitrov; Tom Fahey

doi:10.1370/afm.1640

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Figure 1
Flow diagram of articles on clinical prediction rules in primary care.

Note: The 745 articles included in our review contained data on 895 original studies as many articles described more than 1 clinical prediction rule study. Analyses pertain to 434 unique clinical prediction rules.

^a Articles did not pertain to a clinical prediction rule, were not relevant to primary care, or both.
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Figure 2
Clinical prediction rule studies, split by decade reported and stage of development of the rule (N = 895).

Note: Few studies were reported before 1980; therefore, we grouped these studies into a broader time period (1965–1979).
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Figure 3
Broad clinical domains for the clinical prediction rule studies, split by stage of development of the rule (N = 895).

Note: Studies were classified according to the International Classification of Primary Care, 2nd Edition (ICPC-2).³⁵

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Table 1

Impact Analysis Studies of Clinical Prediction Rules (16 Studies Covering 12 Rules)

Clinical Domain	Clinical Prediction Rule	Author, Year	Clinical Setting	Study Design	Study Outcome
D (Digestive)
D14: Hematemesis/vomiting blood	Blatchford score	Stanley et al, 2009¹⁹	Emergency department	Before-after	Positive
D88: Appendicitis	Alvarado score (MANTRELS)	Farahnak et al, 2007²⁰	Emergency department	RCT (pilot)	Positive
K (Cardiovascular)
K22: Risk factors for cardiovascular disease	UKPDS risk engine (patients with diabetes) with Dutch guidelines risk table	Koelewijnvan Loon et al, 2009²¹	Primary care	Cluster RCT	Negative
	New Zealand risk guidelines for cardiovascular disease	Montgomery et al, 2000²²	Primary care	Cluster RCT	Negative
K74: Ischemic heart disease with angina	Pozen 1984 for admission in acute ischemic heart disease	Pozen et al, 1984²³	Emergency department	On-off	Positive
K93: Pulmonary embolism	Charlotte rule	Kline et al, 2004²⁴	Emergency department	Before-after (controlled)	Positive
	Wells rule for PE	Wells et al, 2003²⁵	Emergency department	Cluster RCT	Positive
L (Musculoskeletal)
L73: Fracture tibia/fibula	Ottawa ankle rule	Bessen et al, 2009²⁶	Emergency department	Before-after	Positive
	Ottawa ankle rule	Auleley et al, 1997²⁷	Emergency department	RCT	Positive
	Ottawa ankle rule	Stiell et al, 1995²⁸	Emergency department	Before-after (controlled)	Positive
	Ottawa ankle rule	Stiell et al, 1994²⁹	Emergency department	Before-after (controlled)	Positive
	Ottawa knee rule	Stiell et al, 1997³⁰	Emergency department	Before-after (controlled)	Positive
N (Neurologic)
N81: Injury nervous system other	Canadian cervical-spine rule	Stiell et al, 2009³¹	Emergency department	Cluster RCT	Positive
R (Respiratory)
R72: Streptococcal pharyngitis	Centor score	Worrall et al, 2007³²	Primary care	RCT	Negative
	McIsaac rule	McIssac et al, 2002³³	Primary care	RCT	Negative
	McIsaac rule	McIssac and Goel, 1998³⁴	Primary care	RCT	Positive

MANTRELS = migration to the right iliac fossa, anorexia, nausea/vomiting, tenderness in the right iliac fossa, rebound pain, elevated temperature (fever), leukocytosis, and shift of leukocytes to the left; PE = pulmonary embolism; RCT = randomized controlled trial; UKPDS = UK Prospective Diabetes Study.

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Table 2

Clinical Setting of Clinical Prediction Rule Studies (N=895)

Clinical Setting	Studies, No. (%)
Primary care: general practice, community, physiotherapy clinic, nursing home, population studies, chiropractor clinic, residential clinic	252 (28.2)
Emergency department	251 (28.0)
Hospital: hospital inpatients, tertiary care, trauma center, stroke unit	150 (16.8)
Specialty clinics: specialty clinics including diabetes, cardiology, prostate, pediatric, arthritis, veteran affairs	122 (13.6)
Hospital inpatients and specialty clinics	24 (2.7)
Primary care and emergency department	6 (0.7)
Prehospital (emergency services)	6 (0.7)
Primary care and specialty clinics	6 (0.7)
Primary care and inpatients	3 (0.3)
Other
Clinical trial/study	27 (3.0)
Setting unclear	43 (4.8)
Guideline/opinion	5 (0.6)

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Supplemental Appendixes 1-2

Supplemental Appendix 1. Journal Selection Criteria; Supplemental Appendix 2: Methodological quality assessment criteria and guidance notes used for assessing (A) derivation; (B) validation studies; (C) impact analysis studies using randomised controlled trial design or cluster randomised controlled trial design; (D) impact analysis studies using controlled before-after design; (E) impact analysis studies using on-off design; (F) Results from all methodological quality assessments.

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Supplemental data: Appendixes 1-2 - PDF file
In Brief

Developing an International Register of Clinical Prediction Rules for Use in Primary Care: A Descriptive Analysis

Tom Fahey , and colleagues

Background Clinical prediction rules (CPRs) are tools that quantify the impact of multiple predictors from a patient's history, physical examination or laboratory results to inform a diagnosis, prognosis, or treatment response. An international web-based register of CPRs is being developed for use in primary care as resource for clinicians. This study summarizes the types of CPRs relevant to primary care used to create this register.

What This Study Found 434 unique and relevant rules were identified, of which slightly more than one-half have been validated at least once; less than 3% have been subjected to an analysis of impact on the process or outcome of clinical care. The rules most commonly pertained to cardiovascular disease, respiratory, and musculoskeletal conditions.

Implications

These findings, the authors assert, support the development of an international register of prediction rules coded by clinical domain and stage of development to help guide areas for needed research and identify those that are ready for use at the point of patient care.