以網路為根據的決策工具有助於小兒科診斷


  2003年5月6日- 一種以網路為基礎的臨床決策制定工具,經過設計可以幫助臨床工作者思考小兒科診斷的範圍,在一項最近的研究中,顯示出這種工具可以根據假設的結果為真實的病例作出診斷。
  
  這項工具稱為伊莎貝爾,是由英國莎貝爾醫療慈善團體所開發的電腦化診斷系統。這是因為醫師未能辨識出一位三歲女孩因水痘而導致壞死性肌膜炎併發症,為了避免這樣的情況再度發生,所以進行研發的工具。
  
  這套系統並非提供輸入症狀後就提出診斷結果,而是為臨床工作者扮演著提示者的角色。目前有超過9,000名註冊的用戶,包括醫生、護士和其它醫療保健專家,每個月收到超過100,000封書面要求。
  
  為了測試它的臨床準確性,英國兒科急症醫院的研究人員比較了這個診斷系統名單對於99起假設病例與100起真實病例。這項研究在2000年8月和12月間進行了二個階段的研究,並且發表於5月號的Archives of Disease in Childhood中。
  
  在99個假設病例中,當病例只與一個單一的診斷結果有關時,伊莎貝爾正確地顯示出預期的診斷,在90個病例有超過一個診斷結果時,也可達到91%的準確性。66起包含唯一診斷的病例中也包括,細菌性肺炎、Crohn氏病和猩紅熱,超過一個診斷結果的33起病例也包括愛滋病、嬰兒臘腸毒菌病和瘧疾等病例。
  
  為了測試伊莎貝爾在100起真實病例的的臨床準確性,研究先請年輕的醫師收集資料,並在包括二間教學醫院和二間綜合醫院進行年齡、臨床特點總整理和診斷。從患者出院的紀錄收集最後的診斷結果。
  
  伊莎貝爾資料庫在87起病例中,得到83起正確的最終診斷結果,達到95%的準確率,但是,最後的13起病例診斷較不具專一性。這是因為伊莎貝爾的資料乃根據課本,有時會出現併發的診斷,如"病毒性疾病"。
  
  伊莎貝爾具有深厚的潛力,可以在臨床工作者作出最後的診斷時,提示各種假設及真正的臨床狀況。尤其這套診斷系統可以協助缺乏臨床經驗和知識的年輕醫師診斷,他們通常在英國的醫療系統中負起診斷患者的大任。但是,還需要進一步研究,使得不熟悉這套工具的臨床工作者可以更善用這套工具。
  
  真正叫做伊莎貝爾女孩已經度過了四個星期的精心照顧,如果她能被及早診斷出,也許就可以避免這個悲劇。
  

Web-Based Decision Tool Aids P

By Cathy Tokarski
Medscape Medical News

May 6, 2003 — A Web-based clinical decision-making tool designed to help clinicians consider a range of pediatric diagnoses showed promising results in a recent study that examined its benefit in hypothetical and real-life cases.

The tool, called ISABEL, is a computerized diagnostic system developed by the ISABEL Medical Charity, a U.K.-registered charity, after doctors in the U.K. failed to identify necrotizing fasciitis complicating chicken pox in a three-year-old girl. Instead of providing a single diagnosis after a patient's symptoms are entered into the system, ISABEL serves as a reminder system of the potentially significant diagnoses that a clinician may have overlooked. It currently has more than 9,000 registered users, including doctors, nurses, and other healthcare professionals, and it receives more than 100,000 page requests each month.

To test its clinical accuracy, researchers at pediatric acute-care hospitals in England compared the system's list of potential diagnoses with the diagnosis given by the clinician in 99 hypothetical cases and 100 real-life cases. The study, reported in the May issue of the Archives of Disease in Childhood, was conducted in two stages between August and December 2000.

Of the 99 hypothetical cases, ISABEL correctly displayed the expected diagnosis (when the case involved a single diagnosis) and all of the expected diagnoses (in cases with more than one diagnosis) in 90 cases, for a 91% accuracy rate. Bacterial pneumonia, Crohn's disease, and scarlet fever were among the conditions in 66 cases involving a single diagnosis. HIV, infant botulism, and malaria were among the conditions in 33 cases with more than one diagnosis, according to the study.

To test ISABEL's clinical accuracy in the 100 real-life cases, junior-level physicians collected data, including age, a summary of clinical features, and the working diagnosis upon admission at two teaching hospitals and two large, general hospitals. The final diagnosis for each patient was collected from the discharge summary record. ISABEL's database displayed the correct final diagnosis in 83 of 87 cases, for a 95% accuracy rate. However, the final diagnosis in 13 cases was not specific. That's because the data in ISABEL is based on textbooks, which sometimes only have nonspecific diagnoses such as "viral illness."

ISABEL has the "potential to remind the clinician of the final diagnosis in a variety of hypothetical as well as real clinical situations," the study concluded. In particular, the authors note, the diagnostic system can help junior physicians who frequently lack "clinical wisdom and knowledge," yet are often called upon to diagnose patients treated in the U.K.'s National Health Service. However, further research must be conducted with clinicians not familiar with the tool's development to better assess its overall utility, they conclude.

The real Isabel spent four weeks in intensive care to save her life, which might have been avoided if her diagnosis was recognized earlier.

Arch Dis Child. 2003;88:408-413

Reviewed by Gary D. Vogin, MD

    
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