title: Translation of clinical prediction rules for febrile children to primary care practice: an observational cohort study.
abstract: BACKGROUND
  Clinical prediction rules (CPRs) to identify children with serious infections lack validation in low-prevalence populations, which hampers their implementation in primary care practice.
  
  
  OBJECTIVE
  To evaluate the diagnostic value of published CPRs for febrile children in primary care.
  
  
  METHODS
  Observational cohort study among febrile children (<16 years) who consulted five GP cooperatives (GPCs) in the Netherlands.
  
  
  METHODS
  Alarm signs of serious infection and clinical management were extracted from routine clinical practice data and manually recoded with a structured electronic data-entry program. Eight CPRs were selected from literature. CPR-variables were matched with alarm signs and CPRs were applied to the GPC-population. 'Referral to emergency department (ED)' was used as a proxy outcome measure for 'serious infection'. CPR performance was assessed by calibration analyses, sensitivity, specificity, and area under the ROC-curve (ROC-area).
  
  
  RESULTS
  A total of 9794 GPC-contacts were eligible, 54% male, median age 2.3 years (interquartile range 1.0-4.6 years) and 8.1% referred to ED. Frequencies of CPR-variables varied from 0.5% (cyanosis, drowsy) to 25% (temperature ≥40°C). Alarm signs frequently included in CPRs were 'ill appearance', 'inconsolable', and 'abnormal circulatory or respiratory signs'. The height of the CPR's predicted risks generally corresponded with being (or not being) referred to the ED in practice. However, calibration-slopes indicated that three CPRs underestimated the risk of serious infection in the GPC-population. Sensitivities ranged from 42% to 54%, specificities from 68% to 89%. ROC-areas ranged from 0.52 to 0.81, with best performance of CPRs for children aged <3 months.
  
  
  CONCLUSIONS
  Published CPRs performed moderately well in the primary out-of-hours care population. Advice is given on how to improve translation of CPRs to primary care practice.
authors.affiliation: Department of General Paediatrics, ErasmusMC - Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, the Netherlands.
authors.forename: Yvette
authors.initials: Y
authors.lastname: van Ierland
authors.affiliation: Department of General Practice;
authors.forename: Gijs
authors.initials: G
authors.lastname: Elshout
authors.affiliation: Department of General Practice, University Groningen, University Medical Center Groningen, Groningen, the Netherlands.
authors.forename: Marjolein Y
authors.initials: MY
authors.lastname: Berger
authors.affiliation: Center for Medical Decision Making;
authors.forename: Yvonne
authors.initials: Y
authors.lastname: Vergouwe
authors.affiliation: ErasmusMC, University Medical Center Rotterdam, Rotterdam, the Netherlands.
authors.forename: Marcel
authors.initials: M
authors.lastname: de Wilde
authors.affiliation: ErasmusMC, University Medical Center Rotterdam, Rotterdam, the Netherlands.
authors.forename: Johan
authors.initials: J
authors.lastname: van der Lei
authors.affiliation: Department of General Paediatrics, ErasmusMC - Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, the Netherlands.
authors.forename: Henriëtte A
authors.initials: HA
authors.lastname: Mol
authors.affiliation: Department of General Paediatrics, ErasmusMC - Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, the Netherlands.
authors.forename: Rianne
authors.initials: R
authors.lastname: Oostenbrink
mesh_terms: D001424:Bacterial Infections / Q000150:complications / Q000175:diagnosis / Q000453:epidemiology / Q000628:therapy; D002675:Child, Preschool; D015331:Cohort Studies; D003661:Decision Support Techniques; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data; D005260:Female; D005334:Fever / Q000175:diagnosis / Q000209:etiology; D006801:Humans; D007223:Infant; D008297:Male; D009426:Netherlands / Q000453:epidemiology; D010346:Patient Care Management / Q000379:methods; D011320:Primary Health Care / Q000379:methods / Q000706:statistics & numerical data; D012372:ROC Curve; D012017:Referral and Consultation / Q000706:statistics & numerical data; D063189:Symptom Assessment / Q000379:methods / Q000706:statistics & numerical data; D057170:Translational Research, Biomedical
keywords: adolescent; bacterial infection; child; child, preschool; decision support techniques; fever; infant; primary health care
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