An examination of clinical intuition in risk assessment among acute coronary syndromes patients: Observations from a prospective multi-center international observational registry
Section snippets
Background
Risk assessment is essential for effective allocation of therapeutic interventions when therapies are associated with the potential for both benefit and harm. “Clinical intuition” plays a large-role in risk assessment, but direct evidence of proficiency compared with established risk scores is limited [1]. The routine invasive strategy of coronary angiography and revascularization in acute coronary syndromes (ACS) represents an archetypical example of this risk-based decision-making challenge.
Study design and population
The Perceived Risk of Ischemic and Bleeding Events in Acute Coronary Syndrome Patients (PREDICT), a prospective multi-center international registry of ACS patients, was conducted in Australia, China, India and Russia (58 hospitals) between May 2009 and February 2011. Details of the study have been published elsewhere [9]. Local ethics approval was obtained at each site with each patient providing informed consent prior to enrolment in the study. Eligible patients presented with either suspected
Results
Of the 1575 patients enrolled, 32 had incomplete data preventing calculation of the GRACE risk score, or were lost to follow-up, leaving 1542 patients (Australia [n = 416], China [n = 495], India [n = 384], and Russia [n = 247]) and 4230 patient-specific physicians estimates. Among the 58 enrolling hospitals, 11 were non-metropolitan hospitals (Australia [3/12], China [1/16], India [5/10], and Russia [2/20]). Of the responding clinicians, 81.4% identified themselves as cardiovascular specialists, with
Discussion
Risk stratification is a critical component of effective and cost effective provision of evidence-based therapies. Several risk scores have been developed as tools to assist in risk stratification in ACS. However, these are not in widespread use and ‘clinical intuition’ has been relied upon historically. Yet much evidence indicates that intuition is inferior to risk scoring [13], [14], [15], [16]. This study of physician-perception of risk compared to risk scoring shows that clinical intuition
Conclusions
Clinical risk assessment among patients with ACS remains highly heterogeneous with variable associations between established clinical risk factors and physician predicted risk. Underestimation of risk is associated with lower use of guideline advocated therapies and increased late mortality. Clinical incorporation of risk stratification coupled with evidence-based decision support should be evaluated in appropriately designed clinical trials.
Acknowledgements
Authorship contributions: Each author has directly contributed to the conduct of this study. All authors have had access to the data and all drafts of the manuscript. Specific contributions are as follows: study design: DC; data collection: SM, CA; data management and analysis: DC, MH; manuscript writing: DPC; manuscript review: all.
Funding sources: role of the sponsor: This study was sponsored by Sanofi-Aventis Asia-Pacific. However, the protocol was conceived and designed by DC, and the
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