Clinical gestalt to diagnose pneumonia, sinusitis, and pharyngitis: a meta-analysis

Background: The overall clinical impression ('clinical gestalt') is widely used for diagnosis but its accuracy has not been systematically studied.

Aim: To determine the accuracy of clinical gestalt for the diagnosis of community-acquired pneumonia (CAP), acute rhinosinusitis (ARS), acute bacterial rhinosinusitis (ABRS), and streptococcal pharyngitis, and to contrast it with the accuracy of clinical decision rules (CDRs).

Design and setting: Systematic review and meta-analysis of outpatient diagnostic accuracy studies in ambulatory care.

Method: PubMed and Google were searched for studies in outpatients that reported sufficient data to calculate accuracy of the overall clinical impression and that used the same reference standard. Study quality was assessed using Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2), and measures of accuracy calculated using bivariate meta-analysis.

Results: The authors identified 16 studies that met the inclusion criteria. The summary estimates for the positive (LR+) and negative likelihood ratios (LR-) were LR+ 7.7, 95% confidence interval (CI) = 4.8 to 11.5, and LR- 0.54, 95% CI = 0.42 to 0.65 for CAP in adults, LR+ 2.7, 95% CI = 1.1 to 4.3 and LR- 0.63, 95% CI = 0.20 to 0.98 for CAP in children, LR+ 3.0, 95% CI = 2.1 to 4.4 and LR- 0.37, 95% CI = 0.29 to 0.46 for ARS in adults, LR+ 3.9, 95% CI = 2.4 to 5.9 and LR- 0.33, 95% CI = 0.20 to 0.50 for ABRS in adults, and LR+ 2.1, 95% CI = 1.6 to 2.8 and LR- 0.47, 95% CI = 0.36 to 0.60 for streptococcal pharyngitis in adults and children. The diagnostic odds ratios were highest for CAP in adults (14.2, 95% CI = 9.0 to 21.0), ARS in adults (8.3, 95% CI = 4.9 to 13.1), and ABRS in adults (13.0, 95% CI = 5.0 to 27.0), as were the C-statistics (0.80, 0.77, and 0.84 respectively).

Conclusion: The accuracy of the overall clinical impression compares favourably with the accuracy of CDRs. Studies of diagnostic accuracy should routinely include the overall clinical impression in addition to individual signs and symptoms, and research is needed to optimise its teaching.