OBJECTIVES: Physicians' gestalt is central in the diagnostic pipeline of suspected COVID-19, due to the absence of a single tool allowing conclusive rule in or out. The aim of this study was to estimate the diagnostic test characteristics of physician's gestalt for COVID-19 in the ED, based on clinical findings or on a combination of clinical findings and bedside imaging results.METHODS: From 1st to 30th of April 2020, patients with suspected COVID-19 were prospectively enrolled in two EDs. Physicians prospectively dichotomized patients in COVID-19 likely or unlikely twice: after medical evaluation of clinical features (clinical gestalt, CG), and after evaluation of clinical features and results of lung ultrasound or chest x-ray (clinical and bedside imaging integrated gestalt, CBIIG). The final diagnosis was adjudicated after independent review of 30-day follow-up data.RESULTS: Among 838 ED enrolled patients, 193 (23%) were finally diagnosed with COVID-19. The area under the curve (AUC), sensitivity and specificity of CG and CBIIG for COVID-19 were 80.8% and 91.6% (p<0.01), 82.9% and 91.4% (p=0.01), 78.6% and 91.8% (p<0.01), respectively. CBIIG had similar AUC and sensitivity to RT-PCR for SARS-CoV-2 on the first nasopharyngeal swab per se (93.5%, p=0.24; and 87%, p=0.17, respectively). CBIIG plus RT-PCR had a sensitivity of 98.4% for COVID-19 (p<0.01 vs RT-PCR alone), as compared to 95.9% for CG plus RT-PCR (p=0.05).CONCLUSIONS: In suspected COVID-19, CG and CBIIG have fair diagnostic accuracy, in line with physicians' gestalt for other acute conditions. Negative RT-PCR plus low probability based on CBIIG can rule out COVID-19 with a relative low number of false negative cases.
Diagnostic accuracy of physician's gestalt in suspected COVID-19. Prospective bicentric study
Morello, Fulvio;Lupia, Enrico;Oddi, Matteo;Grosso, Federico;Pivetta, EmanueleLast
2021-01-01
Abstract
OBJECTIVES: Physicians' gestalt is central in the diagnostic pipeline of suspected COVID-19, due to the absence of a single tool allowing conclusive rule in or out. The aim of this study was to estimate the diagnostic test characteristics of physician's gestalt for COVID-19 in the ED, based on clinical findings or on a combination of clinical findings and bedside imaging results.METHODS: From 1st to 30th of April 2020, patients with suspected COVID-19 were prospectively enrolled in two EDs. Physicians prospectively dichotomized patients in COVID-19 likely or unlikely twice: after medical evaluation of clinical features (clinical gestalt, CG), and after evaluation of clinical features and results of lung ultrasound or chest x-ray (clinical and bedside imaging integrated gestalt, CBIIG). The final diagnosis was adjudicated after independent review of 30-day follow-up data.RESULTS: Among 838 ED enrolled patients, 193 (23%) were finally diagnosed with COVID-19. The area under the curve (AUC), sensitivity and specificity of CG and CBIIG for COVID-19 were 80.8% and 91.6% (p<0.01), 82.9% and 91.4% (p=0.01), 78.6% and 91.8% (p<0.01), respectively. CBIIG had similar AUC and sensitivity to RT-PCR for SARS-CoV-2 on the first nasopharyngeal swab per se (93.5%, p=0.24; and 87%, p=0.17, respectively). CBIIG plus RT-PCR had a sensitivity of 98.4% for COVID-19 (p<0.01 vs RT-PCR alone), as compared to 95.9% for CG plus RT-PCR (p=0.05).CONCLUSIONS: In suspected COVID-19, CG and CBIIG have fair diagnostic accuracy, in line with physicians' gestalt for other acute conditions. Negative RT-PCR plus low probability based on CBIIG can rule out COVID-19 with a relative low number of false negative cases.
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