This Article  • Full text  • PDF  • Send to a friend  • Save in My Folder  • Save to citation manager  • Permissions  Citing Articles  • Citation map  • Citing articles on HighWire  • Citing articles on ISI (144)  • Contact me when this article is cited  Related Content  • Related article  • Similar articles in JAMA  Topic Collections  • Evidence-Based Medicine  • Diagnosis  • Prognosis/ Outcomes  • Alert me on articles by topic

XXII: How to Use Articles About Clinical Decision Rules

Thomas G. McGinn, MD; Gordon H. Guyatt, MD; Peter C. Wyer, MD; C. David Naylor, MD; Ian G. Stiell, MD; W. Scott Richardson, MD; for the Evidence-Based Medicine Working Group

JAMA. 2000;284:79-84.

Clinical experience provides clinicians with an intuitive sense of which findings on history, physical examination, and investigation are critical in making an accurate diagnosis, or an accurate assessment of a patient's fate. A clinical decision rule (CDR) is a clinical tool that quantifies the individual contributions that various components of the history, physical examination, and basic laboratory results make toward the diagnosis, prognosis, or likely response to treatment in a patient. Clinical decision rules attempt to formally test, simplify, and increase the accuracy of clinicians' diagnostic and prognostic assessments. Existing CDRs guide clinicians, establish pretest probability, provide screening tests for common problems, and estimate risk. Three steps are involved in the development and testing of a CDR: creation of the rule, testing or validating the rule, and assessing the impact of the rule on clinical behavior. Clinicians evaluating CDRs for possible clinical use should assess the following components: the method of derivation; the validation of the CDR to ensure that its repeated use leads to the same results; and its predictive power. We consider CDRs that have been validated in a new clinical setting to be level 1 CDRs and most appropriate for implementation. Level 1 CDRs have the potential to inform clinical judgment, to change clinical behavior, and to reduce unnecessary costs, while maintaining quality of care and patient satisfaction.

Author Affiliations: The original list of members (with affiliations) appears in the first article of this series (JAMA. 1993;270:2093-2095). A list of new members appears in the 10th article of the series (JAMA. 1996;275:1435-1439). A full list of the EBM Working Group members, including institutional affiliations and career awards, was presented in the Introduction to this series and in Users' Guide X. The following members contributed to this article: Deborah Cook, MD, Roman Jaeschke, MD, Thomas Newman, MD, Jim Nishikawa, MD, Mark Wilson, MD.

RELATED ARTICLE

July 5, 2000
JAMA. 2000;284(1):115-116.
EXTRACT | FULL TEXT  

THIS ARTICLE HAS BEEN CITED BY OTHER ARTICLES

A formula to predict corrected calcium in haemodialysis patients
Jain et al.
Nephrol Dial Transplant 2008;23:2884-2888.
ABSTRACT | FULL TEXT  

Thromboprophylaxis in cancer outpatients
Doggen
Blood 2008;111:4833-4833.
FULL TEXT  

Development and validation of a predictive model for chemotherapy-associated thrombosis
Khorana et al.
Blood 2008;111:4902-4907.
ABSTRACT | FULL TEXT  

Diagnosis of left ventricular systolic dysfunction (LVSD): development and validation of a clinical prediction rule in primary care
Fahey et al.
Fam Pract 2007;24:628-635.
ABSTRACT | FULL TEXT  

Validation of a Decision Aid to Assist Physicians in Reducing Unnecessary Antibiotic Drug Use for Acute Cystitis
McIsaac et al.
Arch Intern Med 2007;167:2201-2206.
ABSTRACT | FULL TEXT  

Accreditation Council for Graduate Medical Education Competencies: Practice-Based Learning and Systems-Based Practice
Moskowitz and Nash
American Journal of Medical Quality 2007;22:351-382.
 

The 4 item Fracture and Mortality Index predicted hip fracture and all cause mortality in elderly women
Gill
Evid. Based Med. 2007;12:122-122.
FULL TEXT  

Technology Assessment in Radiology: Putting the Evidence in Evidence-based Radiology
Hollingworth and Jarvik
Radiology 2007;244:31-38.
ABSTRACT | FULL TEXT  

Commentary: Reaching a milestone in diagnosing coeliac disease
Graber and Kumar
BMJ 2007;334:732-732.
FULL TEXT  

Arthrokinematics in a Subgroup of Patients Likely to Benefit From a Lumbar Stabilization Exercise Program
Teyhen et al.
ptjournal 2007;87:313-325.
ABSTRACT | FULL TEXT  

Predicting foot ulcers in patients with diabetes: a systematic review and meta-analysis
Crawford et al.
QJM 2007;100:65-86.
ABSTRACT | FULL TEXT  

Clinical Prediction Rule for Identifying Children With Cerebrospinal Fluid Pleocytosis at Very Low Risk of Bacterial Meningitis
Nigrovic et al.
JAMA 2007;297:52-60.
ABSTRACT | FULL TEXT  

Development of a Clinical Prediction Rule for Guiding Treatment of a Subgroup of Patients With Neck Pain: Use of Thoracic Spine Manipulation, Exercise, and Patient Education
Cleland et al.
ptjournal 2007;87:9-23.
ABSTRACT | FULL TEXT  

Accuracy and impact of risk assessment in the primary prevention of cardiovascular disease: a systematic review
Brindle et al.
Heart 2006;92:1752-1759.
ABSTRACT | FULL TEXT  

Primary prevention of cardiovascular disease: a web-based risk score for seven British black and minority ethnic groups
Brindle et al.
Heart 2006;92:1595-1602.
ABSTRACT | FULL TEXT  

How do I perform a lumbar puncture and analyze the results to diagnose bacterial meningitis?
Straus et al.
JAMA 2006;296:2012-2022.
ABSTRACT | FULL TEXT  

The Outpatient Bleeding Risk Index predicted major bleeding in patients taking warfarin
Eikelboom
Evid. Based Med. 2006;11:120-120.
FULL TEXT  

Clinical decision rules to distinguish between bacterial and aseptic meningitis
Dubos et al.
Arch. Dis. Child. 2006;91:647-650.
ABSTRACT | FULL TEXT  

Guidelines for developing and testing clinical decision rules.
Shapiro
West J Nurs Res 2006;28:244-253.
ABSTRACT  

Prediction of vesicoureteral reflux after a first febrile urinary tract infection in children: validation of a clinical decision rule
Leroy et al.
Arch. Dis. Child. 2006;91:241-244.
ABSTRACT | FULL TEXT  

Translating Clinical Research into Clinical Practice: Impact of Using Prediction Rules To Make Decisions
Reilly and Evans
ANN INTERN MED 2006;144:201-209.
ABSTRACT | FULL TEXT  

Development and Application of Clinical Prediction Rules to Improve Decision Making in Physical Therapist Practice
Childs and Cleland
ptjournal 2006;86:122-131.
FULL TEXT  

Prediction of Lyme Meningitis in Children From a Lyme Disease-Endemic Region: A Logistic-Regression Model Using History, Physical, and Laboratory Findings
Avery et al.
Pediatrics 2006;117:e1-e7.
ABSTRACT | FULL TEXT  

Recognising heart failure in elderly patients with stable chronic obstructive pulmonary disease in primary care: cross sectional diagnostic study
Rutten et al.
BMJ 2005;331:1379.
ABSTRACT | FULL TEXT  

Clinical Guidelines and Policies: Can they Improve Emergency Department Pain Management?
Ducharme
J Law Med Ethics 2005;33:783-790.
 

Comparison of the Canadian CT Head Rule and the New Orleans Criteria in Patients With Minor Head Injury
Stiell et al.
JAMA 2005;294:1511-1518.
ABSTRACT | FULL TEXT  

Prognostic Factors in Advanced Cancer Patients: Evidence-Based Clinical Recommendations--A Study by the Steering Committee of the European Association for Palliative Care
Maltoni et al.
JCO 2005;23:6240-6248.
ABSTRACT | FULL TEXT  

Evaluating Clinical Decision Rules
Shapiro
West J Nurs Res 2005;27:655-664.
ABSTRACT  

The Wells Rule Does Not Adequately Rule Out Deep Venous Thrombosis in Primary Care Patients
Oudega et al.
ANN INTERN MED 2005;143:100-107.
ABSTRACT | FULL TEXT  

Use of a Clinical Prediction Score in Patients with Suspected Deep Venous Thrombosis: Two Steps Forward, One Step Back?
Douketis
ANN INTERN MED 2005;143:140-142.
FULL TEXT  

Pro/Con Debate: Lung Allocation Should Be Based on Medical Urgency and Transplant Survival and Not on Waiting Time*
Egan and Kotloff
Chest 2005;128:407-415.
FULL TEXT  

Searching for Evidence-Based Medicine in the Literature Part 3: Assessment
Bartkowiak
Clin Med Res 2005;3:113-115.
FULL TEXT  

Prospective Validation of a Prediction Model for Isolating Inpatients With Suspected Pulmonary Tuberculosis
Wisnivesky et al.
Arch Intern Med 2005;165:453-457.
ABSTRACT | FULL TEXT  

Survival with first-line bosentan in patients with primary pulmonary hypertension
McLaughlin et al.
Eur Respir J 2005;25:244-249.
ABSTRACT | FULL TEXT  

Predicting the Development of Diabetes in Older Adults: The derivation and validation of a prediction rule
Kanaya et al.
Diabetes Care 2005;28:404-408.
ABSTRACT | FULL TEXT  

Limited value of patient history and physical examination in diagnosing deep vein thrombosis in primary care
Oudega et al.
Fam Pract 2005;22:86-91.
ABSTRACT | FULL TEXT  

A Clinical Prediction Rule To Identify Patients with Low Back Pain Most Likely To Benefit from Spinal Manipulation: A Validation Study
Childs et al.
ANN INTERN MED 2004;141:920-928.
ABSTRACT | FULL TEXT  

Clinical Decision Rules as Tools for Evidence-Based Nursing
Shapiro and Driever
West J Nurs Res 2004;26:930-937.
ABSTRACT  

Is radiologic examination necessary for a 9-year-old girl with a knee injury?
Smith and Cleland
ptjournal 2004;84:1092-1100.
FULL TEXT  

Diagnosis of Lower-Extremity Deep Vein Thrombosis in Outpatients With Musculoskeletal Disorders: A National Survey Study of Physical Therapists
Riddle et al.
ptjournal 2004;84:717-728.
ABSTRACT | FULL TEXT  

Which Patients With Knee Problems Are Likely to Benefit From Nonarthroplasty Surgery?: Development of a Clinical Prediction Rule
Solomon et al.
Arch Intern Med 2004;164:509-513.
ABSTRACT | FULL TEXT  

Identification of Individuals With Patellofemoral Pain Whose Symptoms Improved After a Combined Program of Foot Orthosis Use and Modified Activity: A Preliminary Investigation
Sutlive et al.
ptjournal 2004;84:49-61.
ABSTRACT | FULL TEXT  

The Canadian C-Spine Rule versus the NEXUS Low-Risk Criteria in Patients with Trauma
Stiell et al.
NEJM 2003;349:2510-2518.
ABSTRACT | FULL TEXT  

Clinical Diagnosis of Hypersensitivity Pneumonitis
Lacasse et al.
Am. J. Respir. Crit. Care Med. 2003;168:952-958.
ABSTRACT | FULL TEXT  

Probabilistic reasoning and clinical decision-making: do doctors overestimate diagnostic probabilities?
Cahan et al.
QJM 2003;96:763-769.
ABSTRACT | FULL TEXT  

Deferred Care for Emergency Department Users with Nonacute Conditions
Pitts
ANN INTERN MED 2003;139:526-526.
FULL TEXT  

Pathology tests: is the time for demand management ripe at last?
Gopal Rao et al.
J. Clin. Pathol. 2003;56:243-248.
ABSTRACT | FULL TEXT  

Can a Clinical Decision Rule Decrease Antibiotic Use in Viral Meningitis?
Chitkara et al.
Arch Pediatr Adolesc Med 2002;156:1195-1198.
FULL TEXT  

Practice corner: using clinical prediction rules
McGinn et al.
Evid. Based Med. 2002;7:132-134.
FULL TEXT  

Commentary: The prediction of coronary heart disease risk in individuals-- an imprecise science
Brindle and May
Int J Epidemiol 2002;31:822-824.
FULL TEXT  

Impact of a Clinical Decision Rule on Hospital Triage of Patients With Suspected Acute Cardiac Ischemia in the Emergency Department
Reilly et al.
JAMA 2002;288:342-350.
ABSTRACT | FULL TEXT  

The Impact of Empirical Management of Acute Cystitis on Unnecessary Antibiotic Use
McIsaac et al.
Arch Intern Med 2002;162:600-605.
ABSTRACT | FULL TEXT  

Screening for Sleep-Disordered Breathing
Loftin III and Illgen II
Arch Intern Med 2001;161:2634-2635.
FULL TEXT  

The Canadian C-Spine Rule for Radiography in Alert and Stable Trauma Patients
Stiell et al.
JAMA 2001;286:1841-1848.
ABSTRACT | FULL TEXT  

Evaluation of Decision Rules for Referring Women for Bone Densitometry by Dual-Energy X-ray Absorptiometry
Cadarette et al.
JAMA 2001;286:57-63.
ABSTRACT | FULL TEXT  

Searching for Clinical Prediction Rules in MEDLINE
Ingui and Rogers
J. Am. Med. Inform. Assoc. 2001;8:391-397.
ABSTRACT | FULL TEXT  

Development and Validation of a Prognostic Index for 1-Year Mortality in Older Adults After Hospitalization
Walter et al.
JAMA 2001;285:2987-2994.
ABSTRACT | FULL TEXT  

Erythropoietin: A Paradigm for the Development of Practice Guidelines
Rizzo et al.
ASH Education Book 2001;2001:10-30.
ABSTRACT | FULL TEXT  

Indications for Computed Tomography after Minor Head Injury
Stein et al.
NEJM 2000;343:1570-1571.
FULL TEXT  

Clinical decision rules in the emergency department
Stiell
CMAJ 2000;163:1465-1466.
FULL TEXT