Royal College of Surgeons in Ireland Coláiste Ríoga na Máinleá in Éirinn

1. Royal College of Surgeons in IrelandColáiste Ríoga na Máinleá in Éirinn Register of Clinical Prediction Rules, Methodological Quality Assessment and Implementation Strategies Emma Wallace, Claire Keogh, Susan Smith, Borislav D. Dimitrov, Tom Fahey

2. Outline • Section1 • Development of register of Clinical Prediction Rules (CPRs) • Search strategies to identify CPRs relevant to primary care from the MEDLINE database • Section 2 - Methodological quality assessment of CPRs • Section 3 - Implementation strategies

3. SECTION 1 Development of Register of Clinical Prediction Rules (CPRs)

4. Definitions • Clinical Prediction Rule • Clinical tool that quantifies the contribution of • Patient History • Physical Examination • Diagnostic Tests • Stratify patients diagnosis • Probability of having target disorder. • Outcome can be in terms of diagnosis, prognosis, referral or treatment

5. CPR Examples1) Ottawa ankle rule

6. 2) The Centor Score

7. Stages of development of CPR

8. Aim • Develop a web-based register of CPRs for use in primary care as part of Cochrane Primary Healthcare Field

9. CPR register development • Development of an electronic search filter-identify CPRs relevant to primary care • Haynes filter in Clinical Queries • Broad and narrow search filters

10. 30 journals included on the register

11. Methods • Manually searched 30 journals relevant to primary care for the year 2008 (‘reference standard’) • 7 individual electronic searches of the 30 journals (each filter treated as ‘diagnostic tests’) • Test accuracy analysis: Sensitivity and specificity • Aim: to maximise sensitivity

13. Results Manual ‘reference standard’ search retrieved 6344 articles, 41 of which were CPRs

14. MEDLINE versus the final search filter applied to 30 primary care journals (1966 – 2008) Number of articles in PubMEd Year of publication

15. Creating the International Register: Preliminary findings 2008-1980 resulted in 383 CPRs and 141 Questionnaires relevant to primary care * Preliminary findings

16. Overview of classified CPRs

17. Preliminary results: Original articles (n=86)

18. SECTION 2 Methodological Quality assessment of CPR register

19. Health Research Reporting

20. Health Research Reporting • International initiative ‘Equator’ set up in 2008 • Aim to provide resources & education enabling improved reporting and monitor progress • Develop network of reporting guidelines e.g. • CONSORT- RCTs • STARD- Diagnostic Accuracy studies • STROBE- Observational Studies • PRISMA- Systematic reviews

21. Methodological Quality assessment of CPRs • To date Equator have not developed a reporting guideline for CPR Quality assessment • Wasson et al, 1985, Laupacis et al, 1997, Stiell et al 1999,McGinn et al, 2000, Cook et al, 2010 • Different quality markers for derivation and validation CPR studies • Consensus to use McGinn quality checklist due to content and utility

22. Results-preliminary • Quality assessment of a small representative sample of CPR register assessed to date - 2008 as an example

23. Results • 2008 • Derivation CPRs n=18 • Validation CPRs n=20

24. ResultsCPRs (derivation), 2008, n=18

25. ResultsCPRs (validation), 2008, n=20

26. SECTION 3 Implementation strategies

27. Implementation 1.Register of CPRs Cochrane Primary Health Care Field 2. Clinical Decision Support Systems (CDSSs)

28. Register of CPRs Cochrane Primary Health Care Field Implement International Register of CPRs that is; Publicly available, web based, user friendly Searchable across clinical domains Maintained and updated

29. Registry 1 2 3 4 5 6

30. Implementation 1.Register of CPRs Cochrane Primary Health Care Field 2. Clinical Decision Support Systems (CDSSs)

31. Clinical Decision Support Systems

32. Clinical Decision Support Systems • Clinical Decision Support Systems (CDSSs) • Systems that are designed to improve clinical decision making Key points • Integrated with the electronic patient record • Available at the point of care • Computerised knowledge base • Provide patient-specific content

33. Completing evidence base/CPR register Register Systematic reviews