Clinician "gestalt" compares well with decision rules in diagnosing acute respiratory infections

Reference

Dale AP, Marchello C, Ebell MH. Clinical gestalt to diagnose pneumonia, sinusitis, and pharyngitis: a meta-analysis. Br J Gen Pract 2019;69(684):e444-e453.

Synopsis

These authors searched PubMed and Google (limited to the first 50 "hits") to identify prospective studies that compared the accuracy of overall clinical impression (aka gestalt) with clinical decision rules in the diagnosis of various respiratory infections: community-acquired pneumonia, acute rhinosinusitis, acute bacterial rhinosinusitis, and strep pharyngitis. They also manually searched the bibliographies of included studies, as well as published systematic reviews. The authors limited the studies to those taking place in ambulatory care settings: primary care offices, urgent care facilities, and emergency departments. Ultimately they included 16 studies with 6667 patients. Eleven studies included adults only, 4 studies included children only, and 1 study included both. Nine studies evaluated 5627 patients with suspected pneumonia, 3 studies evaluated 498 patients with suspected strep pharyngitis, and 4 studies evaluated 542 patients with suspected rhinosinusitis. Eight of the studies were at low risk of bias, 6 were of moderate risk, and 3 were of high risk. Overall, the clinicians performed well! For community-acquired pneumonia in adults, the clinicians were moderately good at ruling in and ruling out pneumonia (positive likelihood ratio [LR+] 7.7; 95% CI 4.8 - 11.5; negative likelihood ratio [LR-] 0.54; 0.42 - 0.65). However, their diagnoses were less reliable in children (LR+ 2.7; 1.1 - 4.3; LR- 0.63; 0.20 - 0.98). The clinicians were not all that good in diagnosing rhinosinusitis or bacterial sinusitis (LR+ 3 - 4; 2 - 6; LR- 0.3; 0.2 - 0.5) or strep pharyngitis (LR+ 2.1; 1.6 - 2.8; LR- 0.47; 0.36 - 0.60). The decision rules, by the way, performed worse or similar in every instance except in ruling out strep!