Objectives: Physicians’ gestalt is central in the diagnostic pipeline of suspected COVID-19, due to the absence of a single tool allowing conclusive rule in or rule out. The aim of this study was to estimate the diagnostic test characteristics of physician's gestalt for COVID-19 in the emergency department (ED), based on clinical findings or on a combination of clinical findings and bedside imaging results. Methods: From April 1 to April 30, 2020, patients with suspected COVID-19 were prospectively enrolled in two EDs. Physicians prospectively dichotomized patients in COVID-19 likely or unlikely twice: after medical evaluation of clinical features (clinical gestalt [CG]) and after evaluation of clinical features and results of lung ultrasound or chest x-ray (clinical and bedside imaging–integrated gestalt [CBIIG]). The final diagnosis was adjudicated after independent review of 30-day follow-up data. Results: Among 838 ED enrolled patients, 193 (23%) were finally diagnosed with COVID-19. The area under the curve (AUC), sensitivity, and specificity of CG and CBIIG for COVID-19 were 80.8% and 91.6% (p < 0.01), 82.9% and 91.4% (p = 0.01), and 78.6% and 91.8% (p < 0.01), respectively. CBIIG had similar AUC and sensitivity to reverse transcription–polymerase chain reaction (RT-PCR) for SARS-CoV-2 on the first nasopharyngeal swab per se (93.5%, p = 0.24; and 87%, p = 0.17, respectively). CBIIG plus RT-PCR had a sensitivity of 98.4% for COVID-19 (p < 0.01 vs. RT-PCR alone) compared to 95.9% for CG plus RT-PCR (p = 0.05). Conclusions: In suspected COVID-19, CG and CBIIG have fair diagnostic accuracy, in line with physicians’ gestalt for other acute conditions. Negative RT-PCR plus low probability based on CBIIG can rule out COVID-19 with a relatively low number of false-negative cases.
Diagnostic accuracy of physician’s gestalt in suspected COVID-19: Prospective bicentric study / Nazerian P.; Morello F.; Prota A.; Betti L.; Lupia E.; Apruzzese L.; Oddi M.; Grosso F.; Grifoni S.; Pivetta E.; Catini E.; Gualtieri S.; Casanova B.; De Villa E.; Cerini G.; Lumini E.; Gagliano M.; Annovi A.; Mucaj S.; Albanesi M.; Cavigli E.; Moroni C.; Miele V.; Lagi F.; Fanelli A.; Rossolini G.M.; Turco L.; Tomaiuolo M.; Paolini D.; Tonietti B.; Tizzani M.; Locatelli S.M.; Porrino G.; Losano I.; Leone D.; Calzolari G.; Versan M.; Steri F.; Ardito A.; Capuano M.; Gelardi M.; Silvestri G.; Tutto S.; Avolio M.; Cavallo R.; Bartalucci A.; Paglieri C.; Baldassa F.; Baron P.; Bianchi G.; Busso V.; Conterno A.; Del Rizzo P.; Fascio Pecetto P.; Giachino F.; Iannacone A.; Ferrera P.; Riccardini F.; Sacchi C.; Sozzi M.; Totaro S.; Visconti P.; Risi F.; Basile F.; Baricocchi D.; Beaux A.; Valentina B.; Bima P.; Cara I.; Chichizola L.; Dellavalle F.; Labarile G.; Ottimo M.; Pia I.; Scategni V.; Surra A.. - In: ACADEMIC EMERGENCY MEDICINE. - ISSN 1069-6563. - ELETTRONICO. - 28:(2021), pp. 404-411. [10.1111/acem.14232]
Diagnostic accuracy of physician’s gestalt in suspected COVID-19: Prospective bicentric study
Nazerian P.;Apruzzese L.;Grosso F.;Grifoni S.;Catini E.;Gualtieri S.;Casanova B.;De Villa E.;Cerini G.;Lumini E.;Annovi A.;Miele V.;Lagi F.;Rossolini G. M.;Silvestri G.;Riccardini F.;Sacchi C.;Totaro S.;
2021
Abstract
Objectives: Physicians’ gestalt is central in the diagnostic pipeline of suspected COVID-19, due to the absence of a single tool allowing conclusive rule in or rule out. The aim of this study was to estimate the diagnostic test characteristics of physician's gestalt for COVID-19 in the emergency department (ED), based on clinical findings or on a combination of clinical findings and bedside imaging results. Methods: From April 1 to April 30, 2020, patients with suspected COVID-19 were prospectively enrolled in two EDs. Physicians prospectively dichotomized patients in COVID-19 likely or unlikely twice: after medical evaluation of clinical features (clinical gestalt [CG]) and after evaluation of clinical features and results of lung ultrasound or chest x-ray (clinical and bedside imaging–integrated gestalt [CBIIG]). The final diagnosis was adjudicated after independent review of 30-day follow-up data. Results: Among 838 ED enrolled patients, 193 (23%) were finally diagnosed with COVID-19. The area under the curve (AUC), sensitivity, and specificity of CG and CBIIG for COVID-19 were 80.8% and 91.6% (p < 0.01), 82.9% and 91.4% (p = 0.01), and 78.6% and 91.8% (p < 0.01), respectively. CBIIG had similar AUC and sensitivity to reverse transcription–polymerase chain reaction (RT-PCR) for SARS-CoV-2 on the first nasopharyngeal swab per se (93.5%, p = 0.24; and 87%, p = 0.17, respectively). CBIIG plus RT-PCR had a sensitivity of 98.4% for COVID-19 (p < 0.01 vs. RT-PCR alone) compared to 95.9% for CG plus RT-PCR (p = 0.05). Conclusions: In suspected COVID-19, CG and CBIIG have fair diagnostic accuracy, in line with physicians’ gestalt for other acute conditions. Negative RT-PCR plus low probability based on CBIIG can rule out COVID-19 with a relatively low number of false-negative cases.
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