A systematic review of clinical decision rules for the diagnosis of influenza.
OBJECTIVE
In this study, we assessed whether multivariate models and clinical decision rules can be used to reliably diagnose influenza.


METHODS
We conducted a systematic review of MEDLINE, bibliographies of relevant studies, and previous meta-analyses. We searched the literature (1962-2010) for articles evaluating the accuracy of multivariate models, clinical decision rules, or simple heuristics for the diagnosis of influenza. Each author independently reviewed and abstracted data from each article; discrepancies were resolved by consensus discussion. Where possible, we calculated sensitivity, specificity, predictive value, likelihood ratios, and areas under the receiver operating characteristic curve.


RESULTS
A total of 12 studies met our inclusion criteria. No study prospectively validated a multivariate model or clinical decision rule, and no study performed a split-sample or bootstrap validation of such a model. Simple heuristics such as the so-called fever and cough rule and the fever, cough, and acute onset rule were each evaluated by several studies in populations of adults and children. The areas under the receiver operating characteristic curves were 0.70 and 0.79, respectively. We could not calculate a single summary estimate, however, as the diagnostic threshold varied among studies.


CONCLUSIONS
The fever and cough, and the fever, cough, and acute onset heuristics have modest accuracy, but summary estimates could not be calculated. Further research is needed to develop and prospectively validate clinical decision rules to identify patients requiring testing, empiric treatment, or neither.
Department of Epidemiology and Biostatistics, The University of Georgia, Athens, GA, USA. ebell@uga.edu
Mark H
MH
Ebell
Anna
A
Afonso
D003661:Decision Support Techniques; D006801:Humans; D007251:Influenza, Human / Q000175:diagnosis*; D011237:Predictive Value of Tests
J Infect Dis. 2004 Feb 1;189(3):450-8
14745702
J Am Geriatr Soc. 2002 Sep;50(9):1498-503
12383146
Arch Pediatr Adolesc Med. 2004 Apr;158(4):391-4
15066881
Arch Intern Med. 2001 Sep 24;161(17):2116-22
11570941
PLoS One. 2009 Dec 29;4(12):e8453
20041115
Clin Infect Dis. 2000 Nov;31(5):1166-9
11073747
Br J Gen Pract. 2001 Aug;51(469):630-4
11510391
J Am Board Fam Pract. 2004 Jan-Feb;17(1):1-5
15014046
Clin Infect Dis. 1999 Feb;28(2):283-90
10064245
J Clin Virol. 2008 Jun;42(2):190-3
18374630
N Engl J Med. 1980 May 15;302(20):1109-17
7366635
Arch Intern Med. 2000 Nov 27;160(21):3243-7
11088084
Fam Pract. 1998 Feb;15(1):16-22
9527293
PLoS One. 2007 May 23;2(5):e464
17520023
Am Fam Physician. 2005 Nov 1;72(9):1789-92
16300040
Health Technol Assess. 2004 Jun;8(25):iii, 1-234
15193208
JAMA. 2005 Feb 23;293(8):987-97
15728170
Pediatr Emerg Care. 2009 Jun;25(6):369-75
19458562
Arch Pediatr Adolesc Med. 2005 Nov;159(11):1055-62
16275797
Curr Opin Biotechnol. 2002 Feb;13(1):72-6
11849962
Ann Intern Med. 2003 Sep 2;139(5 Pt 1):321-9
12965940
Swiss Med Wkly. 2005 Oct 15;135(41-42):614-7
16402478
Ann Emerg Med. 2005 Nov;46(5):412-9
16271670
Clin Infect Dis. 2006 Sep 1;43(5):564-8
16886147
Infect Control Hosp Epidemiol. 2008 Apr;29(4):314-9
18462143
J Fam Pract. 2001 Dec;50(12):1051-6
11742606
Crit Care Med. 2007 May;35(5):1251-6
17417099
Infect Control Hosp Epidemiol. 2008 Oct;29(10):921-6
18754739
BMC Health Serv Res. 2007 Mar 01;7:33
17328822
Cochrane Database Syst Rev. 2010 Feb 17;(2):CD001265
20166059