Meta-analysis of Calibration, Discrimination, and Stratum-Specific Likelihood Ratios for the CRB-65 Score

Mark H. Ebell, Mary E. Walsh, Tom Fahey, Maggie Kearney, Christian Marchello

Research output: Contribution to journalReview article

1 Citation (Scopus)

Abstract

Background: The CRB-65 score is recommended as a decision support tool to help identify patients with community-acquired pneumonia (CAP) who can safely be treated as outpatients. Objective: To perform an updated meta-analysis of the accuracy, discrimination, and calibration of the CRB-65 score using a novel approach to calculation of stratum-specific likelihood ratios. Design: Meta-analysis of accuracy, discrimination, and calibration. Methods: We searched PubMed, Google, previous systematic reviews, and reference lists of included studies. Data was abstracted and quality assessed in parallel by two investigators. The quality assessment used an adaptation of the TRIPOD and PROBAST criteria. Measures of discrimination, calibration, and stratum-specific likelihood ratios are reported. Key Results: Twenty-nine studies met our inclusion criteria and provided usable data. Most studies were set in Europe, none in North America, and 12 were judged to be at low risk of bias. The pooled estimate of area under the receiver operating characteristic curve was 0.74 (95% CI 0.71–0.77) for all studies. Calibration was good although there was significant heterogeneity; the pooled estimate of the ratio of observed to expected mortality for all studies was 1.04 (95% CI 0.91–1.19). The corresponding values for studies at low risk of bias where patients could be treated as outpatients or inpatients were 0.76 (0.70–0.81) and 0.88 (0.69–1.13). Summary estimates of stratum-specific likelihood ratios for all studies were 0.19 for the low-risk group, 1.1 for the moderate-risk group, and 4.5 for the high-risk group, and 0.13, 1.3, and 5.6 for studies at low risk of bias where patients could be treated as outpatients or inpatients. Conclusions: The CRB-65 is useful for identifying low-risk patients for outpatient therapy. Given a 4% overall mortality risk, patients classified as low risk by the CRB-65 had an outpatient mortality risk of no more than 0.5%.

Original languageEnglish (US)
Pages (from-to)1304-1313
Number of pages10
JournalJournal of General Internal Medicine
Volume34
Issue number7
DOIs
StatePublished - Jul 15 2019
Externally publishedYes

Fingerprint

Calibration
Meta-Analysis
Outpatients
Mortality
Inpatients
North America
PubMed
ROC Curve
Pneumonia
Research Personnel

Keywords

  • CRB-65
  • adults
  • clinical decision rules
  • community-acquired pneumonia
  • meta-analysis
  • risk prediction models

ASJC Scopus subject areas

  • Internal Medicine

Cite this

Meta-analysis of Calibration, Discrimination, and Stratum-Specific Likelihood Ratios for the CRB-65 Score. / Ebell, Mark H.; Walsh, Mary E.; Fahey, Tom; Kearney, Maggie; Marchello, Christian.

In: Journal of General Internal Medicine, Vol. 34, No. 7, 15.07.2019, p. 1304-1313.

Research output: Contribution to journalReview article

Ebell, Mark H. ; Walsh, Mary E. ; Fahey, Tom ; Kearney, Maggie ; Marchello, Christian. / Meta-analysis of Calibration, Discrimination, and Stratum-Specific Likelihood Ratios for the CRB-65 Score. In: Journal of General Internal Medicine. 2019 ; Vol. 34, No. 7. pp. 1304-1313.
@article{576fc2a864064fa781073f49f5600044,
title = "Meta-analysis of Calibration, Discrimination, and Stratum-Specific Likelihood Ratios for the CRB-65 Score",
abstract = "Background: The CRB-65 score is recommended as a decision support tool to help identify patients with community-acquired pneumonia (CAP) who can safely be treated as outpatients. Objective: To perform an updated meta-analysis of the accuracy, discrimination, and calibration of the CRB-65 score using a novel approach to calculation of stratum-specific likelihood ratios. Design: Meta-analysis of accuracy, discrimination, and calibration. Methods: We searched PubMed, Google, previous systematic reviews, and reference lists of included studies. Data was abstracted and quality assessed in parallel by two investigators. The quality assessment used an adaptation of the TRIPOD and PROBAST criteria. Measures of discrimination, calibration, and stratum-specific likelihood ratios are reported. Key Results: Twenty-nine studies met our inclusion criteria and provided usable data. Most studies were set in Europe, none in North America, and 12 were judged to be at low risk of bias. The pooled estimate of area under the receiver operating characteristic curve was 0.74 (95{\%} CI 0.71–0.77) for all studies. Calibration was good although there was significant heterogeneity; the pooled estimate of the ratio of observed to expected mortality for all studies was 1.04 (95{\%} CI 0.91–1.19). The corresponding values for studies at low risk of bias where patients could be treated as outpatients or inpatients were 0.76 (0.70–0.81) and 0.88 (0.69–1.13). Summary estimates of stratum-specific likelihood ratios for all studies were 0.19 for the low-risk group, 1.1 for the moderate-risk group, and 4.5 for the high-risk group, and 0.13, 1.3, and 5.6 for studies at low risk of bias where patients could be treated as outpatients or inpatients. Conclusions: The CRB-65 is useful for identifying low-risk patients for outpatient therapy. Given a 4{\%} overall mortality risk, patients classified as low risk by the CRB-65 had an outpatient mortality risk of no more than 0.5{\%}.",
keywords = "CRB-65, adults, clinical decision rules, community-acquired pneumonia, meta-analysis, risk prediction models",
author = "Ebell, {Mark H.} and Walsh, {Mary E.} and Tom Fahey and Maggie Kearney and Christian Marchello",
year = "2019",
month = "7",
day = "15",
doi = "10.1007/s11606-019-04869-z",
language = "English (US)",
volume = "34",
pages = "1304--1313",
journal = "Journal of General Internal Medicine",
issn = "0884-8734",
publisher = "Springer New York",
number = "7",

}

TY - JOUR

T1 - Meta-analysis of Calibration, Discrimination, and Stratum-Specific Likelihood Ratios for the CRB-65 Score

AU - Ebell, Mark H.

AU - Walsh, Mary E.

AU - Fahey, Tom

AU - Kearney, Maggie

AU - Marchello, Christian

PY - 2019/7/15

Y1 - 2019/7/15

N2 - Background: The CRB-65 score is recommended as a decision support tool to help identify patients with community-acquired pneumonia (CAP) who can safely be treated as outpatients. Objective: To perform an updated meta-analysis of the accuracy, discrimination, and calibration of the CRB-65 score using a novel approach to calculation of stratum-specific likelihood ratios. Design: Meta-analysis of accuracy, discrimination, and calibration. Methods: We searched PubMed, Google, previous systematic reviews, and reference lists of included studies. Data was abstracted and quality assessed in parallel by two investigators. The quality assessment used an adaptation of the TRIPOD and PROBAST criteria. Measures of discrimination, calibration, and stratum-specific likelihood ratios are reported. Key Results: Twenty-nine studies met our inclusion criteria and provided usable data. Most studies were set in Europe, none in North America, and 12 were judged to be at low risk of bias. The pooled estimate of area under the receiver operating characteristic curve was 0.74 (95% CI 0.71–0.77) for all studies. Calibration was good although there was significant heterogeneity; the pooled estimate of the ratio of observed to expected mortality for all studies was 1.04 (95% CI 0.91–1.19). The corresponding values for studies at low risk of bias where patients could be treated as outpatients or inpatients were 0.76 (0.70–0.81) and 0.88 (0.69–1.13). Summary estimates of stratum-specific likelihood ratios for all studies were 0.19 for the low-risk group, 1.1 for the moderate-risk group, and 4.5 for the high-risk group, and 0.13, 1.3, and 5.6 for studies at low risk of bias where patients could be treated as outpatients or inpatients. Conclusions: The CRB-65 is useful for identifying low-risk patients for outpatient therapy. Given a 4% overall mortality risk, patients classified as low risk by the CRB-65 had an outpatient mortality risk of no more than 0.5%.

AB - Background: The CRB-65 score is recommended as a decision support tool to help identify patients with community-acquired pneumonia (CAP) who can safely be treated as outpatients. Objective: To perform an updated meta-analysis of the accuracy, discrimination, and calibration of the CRB-65 score using a novel approach to calculation of stratum-specific likelihood ratios. Design: Meta-analysis of accuracy, discrimination, and calibration. Methods: We searched PubMed, Google, previous systematic reviews, and reference lists of included studies. Data was abstracted and quality assessed in parallel by two investigators. The quality assessment used an adaptation of the TRIPOD and PROBAST criteria. Measures of discrimination, calibration, and stratum-specific likelihood ratios are reported. Key Results: Twenty-nine studies met our inclusion criteria and provided usable data. Most studies were set in Europe, none in North America, and 12 were judged to be at low risk of bias. The pooled estimate of area under the receiver operating characteristic curve was 0.74 (95% CI 0.71–0.77) for all studies. Calibration was good although there was significant heterogeneity; the pooled estimate of the ratio of observed to expected mortality for all studies was 1.04 (95% CI 0.91–1.19). The corresponding values for studies at low risk of bias where patients could be treated as outpatients or inpatients were 0.76 (0.70–0.81) and 0.88 (0.69–1.13). Summary estimates of stratum-specific likelihood ratios for all studies were 0.19 for the low-risk group, 1.1 for the moderate-risk group, and 4.5 for the high-risk group, and 0.13, 1.3, and 5.6 for studies at low risk of bias where patients could be treated as outpatients or inpatients. Conclusions: The CRB-65 is useful for identifying low-risk patients for outpatient therapy. Given a 4% overall mortality risk, patients classified as low risk by the CRB-65 had an outpatient mortality risk of no more than 0.5%.

KW - CRB-65

KW - adults

KW - clinical decision rules

KW - community-acquired pneumonia

KW - meta-analysis

KW - risk prediction models

UR - http://www.scopus.com/inward/record.url?scp=85064703064&partnerID=8YFLogxK

UR - http://www.scopus.com/inward/citedby.url?scp=85064703064&partnerID=8YFLogxK

U2 - 10.1007/s11606-019-04869-z

DO - 10.1007/s11606-019-04869-z

M3 - Review article

VL - 34

SP - 1304

EP - 1313

JO - Journal of General Internal Medicine

JF - Journal of General Internal Medicine

SN - 0884-8734

IS - 7

ER -