Predictive Value of Clinician “Gestalt” in Pediatric Community-Acquired Pneumonia

Abstract

OBJECTIVES: Validated prognostic tools for pediatric community-acquired pneumonia (CAP) do not exist. Thus, clinicians rely on "gestalt" in management decisions for children with CAP. We sought to determine the ability of clinician gestalt to predict severe outcomes. METHODS:We performed a prospective cohort study of children 3 months to 18 years old presenting to a pediatric emergency department (ED) with lower respiratory infection and receiving a chest radiograph for suspected CAP from 2013 to 2017. Clinicians reported the probability that the patient would develop severe complications of CAP (defined as respiratory failure, empyema or effusion, lung abscess or necrosis, metastatic infection, sepsis or septic shock, or death). The primary outcome was development of severe complications.RESULTS: Of 634 children, 37 (5.8%) developed severe complications. Of children developing severe complications after the ED visit, 62.1% were predicted as having ,10% risk by the ED clinician. Sensitivity was .90% at the ,1% predicted risk threshold, whereas specificity was .90% at the 10% risk threshold. Gestalt performance was poor in the low-intermediate predicted risk category (1%-10%). Clinicians had only fair ability to discriminate children developing complications from those who did not (area under the receiver operator characteristic curve 0.747), with worse performance from less experienced clinicians (area under the receiver operator characteristic curve 0.693). CONCLUSIONS:Clinicians have only fair ability to discriminate children with CAP who develop severe complications from those who do not. Clinician gestalt performs best at very low or higher predicted risk thresholds, yet many children fall in the low-moderate predicted risk range in which clinician gestalt is limited. Evidence-based prognostic tools likely can improve on clinician gestalt, particularly when risk is low-moderate.WHAT'S KNOWN ON THIS SUBJECT: Validated prognostic tools do not exist for children with community-acquired pneumonia, leaving clinicians to rely on gestalt for decisionmaking. Data on the predictive ability of clinician gestalt for clinical outcomes in children with respiratory infections are limited.WHAT THIS STUDY ADDS: Clinicians have fair ability to discriminate children with community-acquired pneumonia who develop severe complications. Clinician gestalt performs best at very low or higher predicted risk, yet many children fall in the low-intermediate predicted risk range in which clinician gestalt is more limited.

Concordance in pathogen identification at the upper and lower respiratory tract of children with severe pneumonia

“…Community-acquired pneumonia (CAP) is a common childhood disease and often a reason for hospital admission. CAP remains an important cause of morbidity in the developed world and continues to be associated with high mortality in the developing world [[ 1 ]–[ 2 ]] . CAP can be caused by many different pathogenic microorganisms, most prominently by viruses and bacteria.…”

Pediatric sepsis phenotypes for enhanced therapeutics: An application of clustering to electronic health records

“…Although the features used demonstrated statistically significant ( P < 0.001) clinical distinctions across LCA versus K‐means derived phenotypes, our results may have been biased by high levels of missingness. Additionally our features did not reflect clinician gestalt, known to be especially effective in the management of low and high risk cases, 51 as additional evidence beyond recorded therapies and diagnostic tests. Finally, although restricting the features used for phenotyping modeling to those available in routine clinical practice is reasonable, studies indicate that additional evidence such as advanced biomarkers driven by genomics may contribute in pediatric sepsis phenotyping.…”

Factors associated with severe childhood community-acquired pneumonia: a retrospective study from two hospitals

“…Clinicians rely on their experience or "gestalt" to diagnose childhood pneumonia. However, it turns out that clinicians' gestalt may not be as reliable as we thought it was [14]. The unreliability in clinicians' gestalt is further compounded by poor agreement of examination findings between clinicians in diagnosing CAP [15].…”