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JINJ-5511; No. of Pages 2 Injury, Int. J. Care Injured xxx (2013) xxx–xxx
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Letter to the Editor Re: Is there a need for a clinical decision rule in blunt wrist trauma? Dear Sir/Madam, With great interests we read the study by van den Brandt et al. who aimed to assess the need and feasibility for a clinical decision rule for radiography in patients with blunt wrist trauma [1]. The authors state that, although there were several initiatives to develop such a decision rule [2], the number of X-rays taken in current practice had never been assessed. They demonstrate that 91.4% of all patients with blunt wrist trauma was referred for radiography. Only in 38%, X-rays revealed a fracture of the distal radius, ulna or carpalia. Based on these findings and the checklist for clinical decision rules by Stiell et al. [3], the authors question the feasibility, safety and potential efficiency of a clinical decision rule for patients with blunt wrist trauma. Moreover, they recommend radiography in all patients with blunt wrist trauma presenting to the emergency department. We would like to refute the authors’ conclusion based on the same checklist by Stiell et al. This list considers six stages in the development of a new clinical decision rule. Within the first stage (‘‘is there a need for a clinical decision rule?’’), five standards are discussed: (1) prevalence of the clinical condition; (2) current use of the diagnostic test; (3) variation in practice; (4) attitudes of physicians; and (5) clinical accuracy of physicians. The prevalence, or in this case incidence, of wrist trauma is high and accounts for approximately 20% of all injuries [4–6]. The current use of the diagnostic test is efficient according to the authors, because fractures were common. They compare their results to a previous study by Calvo-Lorenzo et al. [7] who proposed five criteria which resulted in a sensitivity of 100%; and a specificity of 37.7%. Van den Brand et al. claim that their observations on current clinical practice show similar results. With this statement the authors seem to realise what they did. They measured an existing decision rule, that is, the discretion of the treating physician. A simple calculation reveals a sensitivity of 99% and a specificity of 13%. However, it now remains completely unclear which criteria for referral for radiography van den Brand studied. The third prerequisite is variability in practice among similar physicians or institutions [3]. The authors demonstrate a significant difference between two hospitals in the percentage of patients referred for radiography (95% vs. 88%, p < 0.001). This variability is a reflection of the lack of clear guidelines regarding the X-ray
referral policy; and a clear indication that there is indeed a need for a clinical decision rule. The final standard that Stiell stipulates is the accuracy of physicians regarding the interpretation of clinical findings [3]. According to Brandt et al., the accuracy of physicians is ‘‘anything but perfect’’. Obviously the authors feel that physicians cannot be trusted to take patient’s history or perform a physical examination; because, to enhance safety, they propose to send every patient with blunt wrist trauma for radiography. Despite this inaccuracy, van den Brand et al. argue that it would be hard to introduce a decision rule that is safe and more efficient than current practice. Moreover, they claim that the use of the criteria by Calvo-Lorenzo on their population would result in a higher referral ratio than the 84.4% reported by Calvo-Lorenzo. However, if their current practice were based on these criteria (100% sensitivity and 37.7% specificity), the referral ratio would drop from 91.4% to 79%. This is a relative reduction of 14%. Even at the low rate of 50 US dollars per X-ray, the potential cost-savings could be substantial. There is always a trade-off between efficiency and safety. It is very safe to refer every patient for every diagnostic test; and consequently, not very efficient. Nevertheless, referring every patient for radiography would be rash and not appropriate in light of the ever-rising costs in health care. Fortunately, the need for a clinical decision rule in wrist trauma is now substantiated by the results of this study: (1) there is a significant variability in referral ratio between two similar hospitals; and (2) the referral criteria are obscure and unfounded. We would therefore like to thank van den Brand et al. for confirming the importance of our current study: The development of the Amsterdam Wrist Rules [1]. Conflicts of interest statement The authors state that there are no financial or personal conflicts of interest. References [1] van den Brand CL, van Leerdam RH, van Ufford JH, Rhemrev SJ. Is there a need for a clinical decision rule in blunt wrist trauma? Injury 2013. http://dx.doi.org/ 10.1016/j.injury.2013.07.006. [2] Bentohami A, Walenkamp MMJ, Slaar A, Beerekamp MSH, de Groot JAH, Verhoog EM, et al. Amsterdam wrist rules: a clinical decision aid. BMC Musculoskelet Disord 2011;12:238. http://dx.doi.org/10.1186/1471-2474-12-238. [3] Stiell IG, Wells GA. Methodologic standards for the development of clinical decision rules in emergency medicine. Ann Emerg Med 1999;33(4):437–47.
0020–1383/$ – see front matter ß 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.injury.2013.09.033
Please cite this article in press as: Walenkamp MMJ, Schep NWL. Re: Is there a need for a clinical decision rule in blunt wrist trauma?. Injury (2013), http://dx.doi.org/10.1016/j.injury.2013.09.033
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JINJ-5511; No. of Pages 2 2
Letter to the Editor / Injury, Int. J. Care Injured xxx (2013) xxx–xxx
[4] Larsen CF, Mulder S, Johansen AM, Stam C. The epidemiology of hand injuries in the Netherlands and Denmark. Eur J Epidemiol 2004;19(4):323–7. http:// dx.doi.org/10.1023/B:EJEP.0000024662.32024.e3. [5] de Putter CE, Selles RW, Polinder S, Panneman MJ, Hovius SE, van Beeck EF. Economic impact of hand and wrist injuries: health-care costs and productivity costs in a population-based study. J Bone Joint Surg Am 2012;94(9):e56. http:// dx.doi.org/10.2106/JBJS.K.00561. [6] Angermann P, Lohmann M. Hand and wrist injuries. A study of 50.272 injuries. Ugeskr Laeger 1995;157(6):734–7. [7] Calvo-Lorenzo I, Martı´nez-de la Llana O, Blanco-Santiago D, Zabala-Echenagusia J, Laita-Legarreta A, Azores-Galeano X. Would it be possible to develop a set of ottawa wrist rules to facilitate clinical decision making? Rev Esp Cir Ortop Traumatol (English Ed) 2008;52(5):315–21. http://dx.doi.org/10.1016/S19888856(08)70115-9.
M.M.J. Walenkamp* N.W.L. Schep Trauma Unit, Department of Surgery, Academic Medical Center, P.O. BOX 22660, 1100 DD Amsterdam, The Netherlands *Corresponding author E-mail address: [email protected] (M.M.J. Walenkamp)
Please cite this article in press as: Walenkamp MMJ, Schep NWL. Re: Is there a need for a clinical decision rule in blunt wrist trauma?. Injury (2013), http://dx.doi.org/10.1016/j.injury.2013.09.033
JINJ-5511; No. of Pages 2 Injury, Int. J. Care Injured xxx (2013) xxx–xxx
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Letter to the Editor Re: Is there a need for a clinical decision rule in blunt wrist trauma? Dear Sir/Madam, With great interests we read the study by van den Brandt et al. who aimed to assess the need and feasibility for a clinical decision rule for radiography in patients with blunt wrist trauma [1]. The authors state that, although there were several initiatives to develop such a decision rule [2], the number of X-rays taken in current practice had never been assessed. They demonstrate that 91.4% of all patients with blunt wrist trauma was referred for radiography. Only in 38%, X-rays revealed a fracture of the distal radius, ulna or carpalia. Based on these findings and the checklist for clinical decision rules by Stiell et al. [3], the authors question the feasibility, safety and potential efficiency of a clinical decision rule for patients with blunt wrist trauma. Moreover, they recommend radiography in all patients with blunt wrist trauma presenting to the emergency department. We would like to refute the authors’ conclusion based on the same checklist by Stiell et al. This list considers six stages in the development of a new clinical decision rule. Within the first stage (‘‘is there a need for a clinical decision rule?’’), five standards are discussed: (1) prevalence of the clinical condition; (2) current use of the diagnostic test; (3) variation in practice; (4) attitudes of physicians; and (5) clinical accuracy of physicians. The prevalence, or in this case incidence, of wrist trauma is high and accounts for approximately 20% of all injuries [4–6]. The current use of the diagnostic test is efficient according to the authors, because fractures were common. They compare their results to a previous study by Calvo-Lorenzo et al. [7] who proposed five criteria which resulted in a sensitivity of 100%; and a specificity of 37.7%. Van den Brand et al. claim that their observations on current clinical practice show similar results. With this statement the authors seem to realise what they did. They measured an existing decision rule, that is, the discretion of the treating physician. A simple calculation reveals a sensitivity of 99% and a specificity of 13%. However, it now remains completely unclear which criteria for referral for radiography van den Brand studied. The third prerequisite is variability in practice among similar physicians or institutions [3]. The authors demonstrate a significant difference between two hospitals in the percentage of patients referred for radiography (95% vs. 88%, p < 0.001). This variability is a reflection of the lack of clear guidelines regarding the X-ray
referral policy; and a clear indication that there is indeed a need for a clinical decision rule. The final standard that Stiell stipulates is the accuracy of physicians regarding the interpretation of clinical findings [3]. According to Brandt et al., the accuracy of physicians is ‘‘anything but perfect’’. Obviously the authors feel that physicians cannot be trusted to take patient’s history or perform a physical examination; because, to enhance safety, they propose to send every patient with blunt wrist trauma for radiography. Despite this inaccuracy, van den Brand et al. argue that it would be hard to introduce a decision rule that is safe and more efficient than current practice. Moreover, they claim that the use of the criteria by Calvo-Lorenzo on their population would result in a higher referral ratio than the 84.4% reported by Calvo-Lorenzo. However, if their current practice were based on these criteria (100% sensitivity and 37.7% specificity), the referral ratio would drop from 91.4% to 79%. This is a relative reduction of 14%. Even at the low rate of 50 US dollars per X-ray, the potential cost-savings could be substantial. There is always a trade-off between efficiency and safety. It is very safe to refer every patient for every diagnostic test; and consequently, not very efficient. Nevertheless, referring every patient for radiography would be rash and not appropriate in light of the ever-rising costs in health care. Fortunately, the need for a clinical decision rule in wrist trauma is now substantiated by the results of this study: (1) there is a significant variability in referral ratio between two similar hospitals; and (2) the referral criteria are obscure and unfounded. We would therefore like to thank van den Brand et al. for confirming the importance of our current study: The development of the Amsterdam Wrist Rules [1]. Conflicts of interest statement The authors state that there are no financial or personal conflicts of interest. References [1] van den Brand CL, van Leerdam RH, van Ufford JH, Rhemrev SJ. Is there a need for a clinical decision rule in blunt wrist trauma? Injury 2013. http://dx.doi.org/ 10.1016/j.injury.2013.07.006. [2] Bentohami A, Walenkamp MMJ, Slaar A, Beerekamp MSH, de Groot JAH, Verhoog EM, et al. Amsterdam wrist rules: a clinical decision aid. BMC Musculoskelet Disord 2011;12:238. http://dx.doi.org/10.1186/1471-2474-12-238. [3] Stiell IG, Wells GA. Methodologic standards for the development of clinical decision rules in emergency medicine. Ann Emerg Med 1999;33(4):437–47.
0020–1383/$ – see front matter ß 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.injury.2013.09.033
Please cite this article in press as: Walenkamp MMJ, Schep NWL. Re: Is there a need for a clinical decision rule in blunt wrist trauma?. Injury (2013), http://dx.doi.org/10.1016/j.injury.2013.09.033
G Model
JINJ-5511; No. of Pages 2 2
Letter to the Editor / Injury, Int. J. Care Injured xxx (2013) xxx–xxx
[4] Larsen CF, Mulder S, Johansen AM, Stam C. The epidemiology of hand injuries in the Netherlands and Denmark. Eur J Epidemiol 2004;19(4):323–7. http:// dx.doi.org/10.1023/B:EJEP.0000024662.32024.e3. [5] de Putter CE, Selles RW, Polinder S, Panneman MJ, Hovius SE, van Beeck EF. Economic impact of hand and wrist injuries: health-care costs and productivity costs in a population-based study. J Bone Joint Surg Am 2012;94(9):e56. http:// dx.doi.org/10.2106/JBJS.K.00561. [6] Angermann P, Lohmann M. Hand and wrist injuries. A study of 50.272 injuries. Ugeskr Laeger 1995;157(6):734–7. [7] Calvo-Lorenzo I, Martı´nez-de la Llana O, Blanco-Santiago D, Zabala-Echenagusia J, Laita-Legarreta A, Azores-Galeano X. Would it be possible to develop a set of ottawa wrist rules to facilitate clinical decision making? Rev Esp Cir Ortop Traumatol (English Ed) 2008;52(5):315–21. http://dx.doi.org/10.1016/S19888856(08)70115-9.
M.M.J. Walenkamp* N.W.L. Schep Trauma Unit, Department of Surgery, Academic Medical Center, P.O. BOX 22660, 1100 DD Amsterdam, The Netherlands *Corresponding author E-mail address: [email protected] (M.M.J. Walenkamp)
Please cite this article in press as: Walenkamp MMJ, Schep NWL. Re: Is there a need for a clinical decision rule in blunt wrist trauma?. Injury (2013), http://dx.doi.org/10.1016/j.injury.2013.09.033
