title: The test characteristics of physician clinical gestalt for determining the presence and severity of anaemia in patients seen at the emergency department of a tertiary referral hospital in Tanzania.
abstract: OBJECTIVE
  To evaluate the test characteristics of clinical gestalt for detecting the presence and severity of anaemia in emergency department patients at a tertiary referral hospital in Tanzania.
  
  
  METHODS
  This prospective study enrolled a convenience sample of emergency department patients who had a complete blood count ordered by the treating physician in the course of their clinical care. Physicians recorded their impression of the presence and severity of anaemia before viewing the laboratory results. To assess interobserver agreement, a second physician provided their blinded gestalt impression of the patient's haemoglobin level.
  
  
  RESULTS
  We enrolled 216 patients and complete data were available for 210 patients (97%), 59% male, median age 30 years. The range of measured haemoglobin values was 1.5-15.4 g/dL. The physicians rated anaemia mild or absent in 74 (35%), moderate in 72 (34%) and severe in 64 patients (30%). These estimates were significantly concordant with the laboratory haemoglobin measurements (Kendall's τ b=0.63, 95% CI 0.57 to 0.69, p<0.0001). The test characteristics of physician gestalt estimates for severe anaemia were: sensitivity 64% (95% CI 53% to 74%), specificity 91% (95% CI 85% to 96%), positive likelihood ratio of 7.4 (95% CI 4.2 to 13.3) and negative likelihood ratio of 0.40 (0.3 to 0.5). The weighted Cohen's κ for interobserver agreement between physicians on the gestalt estimate of the degree of anaemia was 0.87 (95% CI 0.76 to 0.98).
  
  
  CONCLUSIONS
  Physicians' estimates of the severity of anaemia were significantly concordant with laboratory haemoglobin measurements. Sensitivity of the gestalt estimate for severe anaemia was moderate. Interobserver agreement was 'almost perfect'.
authors.affiliation: Emergency Medicine Department, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania Emergency Medicine Department, Muhimbili National Hospital, Dar es Salaam, Tanzania.
authors.forename: Hendry Robert
authors.initials: HR
authors.lastname: Sawe
authors.affiliation: Emergency Medicine Department, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania Emergency Medicine Department, Muhimbili National Hospital, Dar es Salaam, Tanzania.
authors.forename: Juma A
authors.initials: JA
authors.lastname: Mfinanga
authors.affiliation: Emergency Medicine Department, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania Emergency Medicine Department, Muhimbili National Hospital, Dar es Salaam, Tanzania.
authors.forename: Victor
authors.initials: V
authors.lastname: Mwafongo
authors.affiliation: Emergency Medicine Department, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania Department of Emergency Medicine and Global Health Sciences, University of California San Francisco, San Francisco, California, USA.
authors.forename: Teri A
authors.initials: TA
authors.lastname: Reynolds
authors.affiliation: Emergency Medicine Department, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania Department of Emergency Medicine, Carolinas Medical Center, Charlotte, North Carolina, USA.
authors.forename: Michael S
authors.initials: MS
authors.lastname: Runyon
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000740:Anemia / Q000175:diagnosis*; D002648:Child; D002675:Child, Preschool; D002983:Clinical Competence / Q000592:standards; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data*; D005260:Female; D005863:Gestalt Theory; D006454:Hemoglobins / Q000032:analysis; D006801:Humans; D007223:Infant; D008297:Male; D008875:Middle Aged; D015588:Observer Variation; D010808:Physical Examination / Q000592:standards*; D011446:Prospective Studies; D012680:Sensitivity and Specificity; D013636:Tanzania; D055815:Young Adult
chemical_list: D006454:Hemoglobins
keywords: clincial management; diagnosis; emergency department management