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Johannes N Keeman - One of the best experts on this subject based on the ideXlab platform.
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radiography in acute Ankle injuries the Ottawa Ankle Rules versus local diagnostic decision Rules
Annals of Emergency Medicine, 2002Co-Authors: A C M Pijnenburg, Afina S Glas, Marnix A J De Roos, Kjell Bogaard, Jeroen G Lijmer, Patrick M Bossuyt, Rudolf M J M Butzelaar, Johannes N KeemanAbstract:Abstract Study Objective: We validate the Ottawa Ankle Rules and 2 Dutch Ankle Rules in distinguishing clinically significant fractures from insignificant fractures and other injuries in patients with a painful Ankle presenting to the emergency department. Methods: This prospective comparison of 3 Ankle Rules was conducted in the ED of a 580-bed community teaching hospital in Amsterdam from January 1998 to April 1999. Participants included 647 consecutive patients aged 18 years or older presenting with a painful Ankle after trauma. All physicians received extensive and pictorial training on how to correctly score the respective items of the Rules. The physician on call recorded these items derived from history and physical examination on a standardized data sheet. All patients subsequently underwent standard radiographic assessment. A radiologist and a trauma surgeon evaluated the radiographs blinded from the results of the data sheet form and the treatment given. The diagnostic performance of the 3 Rules was measured in terms of sensitivity, specificity, and the reduction of radiographs. Receiver operating characteristic (ROC) curves were constructed, and the area under the ROC curves was calculated and compared. Results: Seventy-four fractures were seen, of which 41 were clinically significant. The Ottawa Ankle Rules had a sensitivity of 98% for identifying clinically significant fractures; the local Rules scored 88% and 59%, respectively. The potential savings in radiographs for the 3 decision Rules were 24%, 54%, and 82%, respectively. The area under the ROC curve was better for both the local Rules (0.84 and 0.83) compared with the Ottawa Ankle Rules (0.76). Conclusion: Because the identification of all relevant fractures is more important than a reduction in radiographs, the higher sensitivity of the Ottawa Ankle Rules makes these most suitable for implementation in The Netherlands. [Pijnenburg ACM, Glas AS, de Roos MAJ, Bogaard K, Lijmer JG, Bossuyt PMM, Butzelaar RMJM, Keeman JN. Radiography in acute Ankle injuries: the Ottawa Ankle Rules versus local diagnostic decision Rules. Ann Emerg Med. June 2002;39:599-604.]
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radiography in acute Ankle injuries the Ottawa Ankle Rules versus local diagnostic decision Rules
International Ankle symposium, 2002Co-Authors: A C M Pijnenburg, Afina S Glas, Marnix A J De Roos, Kjell Bogaard, Jeroen G Lijmer, Patrick M Bossuyt, Rudolf M J M Butzelaar, Johannes N KeemanAbstract:Study objective: We validate the Ottawa Ankle Rules and 2 Dutch Ankle Rules in distinguishing clinically significant fractures from insignificant fractures and other injuries in patients with a painful Ankle presenting to the emergency department. Methods: This prospective comparison of 3 Ankle Rules was conducted in the ED of a 580-bed community teaching hospital in Amsterdam from January 1998 to April 1999. Participants included 647 consecutive patients aged 18 years or older presenting with a painful Ankle after trauma. All physicians received extensive and pictorial training on how to correctly score the respective items of the Rules. The physician on call recorded these items derived from history and physical examination on a standardized data sheet All patients subsequently underwent standard radiographic assessment. A radiologist and a trauma surgeon evaluated the radiographs blinded from the results of the data sheet form and the treatment given. The diagnostic performance of the 3 Rules was measured in terms of sensitivity, specificity, and the reduction of radiographs. Receiver operating characteristic (ROC) curves were constructed, and the area under the ROC curves was calculated and compared. Results: Seventy-four fractures were seen, of which 41 were clinically significant. The Ottawa Ankle Rules had a sensitivity of 98% for identifying clinically significant fractures; the local Rules scored 88% and 59%, respectively. The potential savings in radiographs for the 3 decision Rules were 24%, 54%, and 82%, respectively. The area under the ROC curve was better for both the local Rules (0.84 and 0.83) compared with the Ottawa Ankle Rules (0.76). Conclusion: Because the identification of all relevant fractures is more important than a reduction in radiographs, the higher sensitivity of the Ottawa Ankle Rules makes these most suitable for implementation in The Netherlands.
Dean C Taylor - One of the best experts on this subject based on the ideXlab platform.
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a prospective study of modified Ottawa Ankle Rules in a military population interobserver agreement between physical therapists and orthopaedic surgeons
American Journal of Sports Medicine, 2000Co-Authors: Barbara A Springer, Robert A Arciero, Joachim J Tenuta, Dean C TaylorAbstract:To determine the necessity of Ankle and foot radiographs, we used modified Ottawa Ankle Rules to evaluate all cadets seen with an acute Ankle or midfoot injury at the United States Military Academy. This scoring system determines the need for radiographs. Each patient was independently examined and the decision Rules were applied by a physical therapist and an orthopaedic surgeon. Ankle and foot radiographs were obtained for all subjects. Sensitivity, specificity, and the positive predictive value were calculated in 153 patients. There were six clinically significant Ankle fractures and three midfoot fractures, for a total incidence of 5.8%. For physical therapists, the sensitivity was 100%, the specificity for Ankle injuries was 40%, and the specificity for foot injuries was 79%. For orthopaedic surgeons, the sensitivity was also 100%, the specificity for Ankle injuries was 46%, and the specificity for foot injuries was 79%. Interobserver agreement between the orthopaedic surgeons and physical therapists regarding the overall decision to obtain radiographs was high, with a kappa coefficient value of 0.82 for Ankle injuries and 0.88 for foot injuries. There were no false-negative results. Use of the modified Ottawa Ankle Rules would have reduced the necessity for Ankle and foot radiographs by 46% and 79%, respectively.
A C M Pijnenburg - One of the best experts on this subject based on the ideXlab platform.
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radiography in acute Ankle injuries the Ottawa Ankle Rules versus local diagnostic decision Rules
Annals of Emergency Medicine, 2002Co-Authors: A C M Pijnenburg, Afina S Glas, Marnix A J De Roos, Kjell Bogaard, Jeroen G Lijmer, Patrick M Bossuyt, Rudolf M J M Butzelaar, Johannes N KeemanAbstract:Abstract Study Objective: We validate the Ottawa Ankle Rules and 2 Dutch Ankle Rules in distinguishing clinically significant fractures from insignificant fractures and other injuries in patients with a painful Ankle presenting to the emergency department. Methods: This prospective comparison of 3 Ankle Rules was conducted in the ED of a 580-bed community teaching hospital in Amsterdam from January 1998 to April 1999. Participants included 647 consecutive patients aged 18 years or older presenting with a painful Ankle after trauma. All physicians received extensive and pictorial training on how to correctly score the respective items of the Rules. The physician on call recorded these items derived from history and physical examination on a standardized data sheet. All patients subsequently underwent standard radiographic assessment. A radiologist and a trauma surgeon evaluated the radiographs blinded from the results of the data sheet form and the treatment given. The diagnostic performance of the 3 Rules was measured in terms of sensitivity, specificity, and the reduction of radiographs. Receiver operating characteristic (ROC) curves were constructed, and the area under the ROC curves was calculated and compared. Results: Seventy-four fractures were seen, of which 41 were clinically significant. The Ottawa Ankle Rules had a sensitivity of 98% for identifying clinically significant fractures; the local Rules scored 88% and 59%, respectively. The potential savings in radiographs for the 3 decision Rules were 24%, 54%, and 82%, respectively. The area under the ROC curve was better for both the local Rules (0.84 and 0.83) compared with the Ottawa Ankle Rules (0.76). Conclusion: Because the identification of all relevant fractures is more important than a reduction in radiographs, the higher sensitivity of the Ottawa Ankle Rules makes these most suitable for implementation in The Netherlands. [Pijnenburg ACM, Glas AS, de Roos MAJ, Bogaard K, Lijmer JG, Bossuyt PMM, Butzelaar RMJM, Keeman JN. Radiography in acute Ankle injuries: the Ottawa Ankle Rules versus local diagnostic decision Rules. Ann Emerg Med. June 2002;39:599-604.]
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radiography in acute Ankle injuries the Ottawa Ankle Rules versus local diagnostic decision Rules
International Ankle symposium, 2002Co-Authors: A C M Pijnenburg, Afina S Glas, Marnix A J De Roos, Kjell Bogaard, Jeroen G Lijmer, Patrick M Bossuyt, Rudolf M J M Butzelaar, Johannes N KeemanAbstract:Study objective: We validate the Ottawa Ankle Rules and 2 Dutch Ankle Rules in distinguishing clinically significant fractures from insignificant fractures and other injuries in patients with a painful Ankle presenting to the emergency department. Methods: This prospective comparison of 3 Ankle Rules was conducted in the ED of a 580-bed community teaching hospital in Amsterdam from January 1998 to April 1999. Participants included 647 consecutive patients aged 18 years or older presenting with a painful Ankle after trauma. All physicians received extensive and pictorial training on how to correctly score the respective items of the Rules. The physician on call recorded these items derived from history and physical examination on a standardized data sheet All patients subsequently underwent standard radiographic assessment. A radiologist and a trauma surgeon evaluated the radiographs blinded from the results of the data sheet form and the treatment given. The diagnostic performance of the 3 Rules was measured in terms of sensitivity, specificity, and the reduction of radiographs. Receiver operating characteristic (ROC) curves were constructed, and the area under the ROC curves was calculated and compared. Results: Seventy-four fractures were seen, of which 41 were clinically significant. The Ottawa Ankle Rules had a sensitivity of 98% for identifying clinically significant fractures; the local Rules scored 88% and 59%, respectively. The potential savings in radiographs for the 3 decision Rules were 24%, 54%, and 82%, respectively. The area under the ROC curve was better for both the local Rules (0.84 and 0.83) compared with the Ottawa Ankle Rules (0.76). Conclusion: Because the identification of all relevant fractures is more important than a reduction in radiographs, the higher sensitivity of the Ottawa Ankle Rules makes these most suitable for implementation in The Netherlands.
Barbara A Springer - One of the best experts on this subject based on the ideXlab platform.
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a prospective study of modified Ottawa Ankle Rules in a military population interobserver agreement between physical therapists and orthopaedic surgeons
American Journal of Sports Medicine, 2000Co-Authors: Barbara A Springer, Robert A Arciero, Joachim J Tenuta, Dean C TaylorAbstract:To determine the necessity of Ankle and foot radiographs, we used modified Ottawa Ankle Rules to evaluate all cadets seen with an acute Ankle or midfoot injury at the United States Military Academy. This scoring system determines the need for radiographs. Each patient was independently examined and the decision Rules were applied by a physical therapist and an orthopaedic surgeon. Ankle and foot radiographs were obtained for all subjects. Sensitivity, specificity, and the positive predictive value were calculated in 153 patients. There were six clinically significant Ankle fractures and three midfoot fractures, for a total incidence of 5.8%. For physical therapists, the sensitivity was 100%, the specificity for Ankle injuries was 40%, and the specificity for foot injuries was 79%. For orthopaedic surgeons, the sensitivity was also 100%, the specificity for Ankle injuries was 46%, and the specificity for foot injuries was 79%. Interobserver agreement between the orthopaedic surgeons and physical therapists regarding the overall decision to obtain radiographs was high, with a kappa coefficient value of 0.82 for Ankle injuries and 0.88 for foot injuries. There were no false-negative results. Use of the modified Ottawa Ankle Rules would have reduced the necessity for Ankle and foot radiographs by 46% and 79%, respectively.
Ian G Stiell - One of the best experts on this subject based on the ideXlab platform.
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awareness and use of the Ottawa Ankle and knee Rules in 5 countries can publication alone be enough to change practice
Annals of Emergency Medicine, 2001Co-Authors: Ian D Graham, Ian G Stiell, Andreas Laupacis, Pierre Durieux, Laura Mcauley, Michael D Howell, Michael Clancy, Nicholas Simon, Jose I Emparanza, Jose R AginagaAbstract:Abstract Study Objectives: We evaluate the international diffusion of the Ottawa Ankle and Knee Rules and determine emergency physicians' attitudes toward clinical decision Rules in general. Methods: We conducted a cross-sectional, self-administered mail survey of random samples of 500 members each of the American College of Emergency Physicians, Canadian Association of Emergency Physicians, British Association for Accident and Emergency Medicine, Spanish Society for Emergency Medicine, and all members (n=1,350) of the French Speaking Society of Emergency Physicians, France. Main outcome measures were awareness of the Ottawa Ankle and Knee Rules, reported use of these Rules, and attitudes toward clinical decision Rules in general. Results: A total of 1,769 (57%) emergency physicians responded, with country-specific response rates between 49% (United States and France) and 79% (Canada). More than 69% of physicians in all countries, except Spain, were aware of the Ottawa Ankle Rules. Use of the Ottawa Ankle Rules differed by country with more than 70% of all responding Canadian and United Kingdom physicians reporting frequent use of the Rules compared with fewer than one third of US, French, and Spanish physicians. The Ottawa Knee Rule was less well known and less used by physicians in all countries. Most physicians in all countries viewed decision Rules as intended to improve the quality of health care (>78%), a convenient source of advice (>67%), and good educational tools (>61%). Of all physicians, those from the United States held the least positive attitudes toward decision Rules. Conclusion: This constitutes the largest international survey of emergency physicians' attitudes toward and use of clinical decision Rules. Striking differences were apparent among countries with regard to knowledge and use of decision Rules. Despite similar awareness in the United States, Canada, and the United Kingdom, US physicians appeared much less likely to use the Ottawa Ankle Rules. Future research should investigate factors leading to differences in rates of diffusion among countries and address strategies to enhance dissemination and implementation of such Rules in the emergency department. [Graham ID, Stiell IG, Laupacis A, McAuley L, Howell M, Clancy M, Durieux P, Simon N, Emparanza JI, Aginaga JR, O'Connor A, Wells G. Awareness and use of the Ottawa Ankle and Knee Rules in 5 countries: can publication alone be enough to change practice? Ann Emerg Med. March 2001;37:259-266.]
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validation of the Ottawa Ankle Rules in children with Ankle injuries
Academic Emergency Medicine, 1999Co-Authors: Amy C Plint, Ian G Stiell, Blake Bulloch, Martin H Osmond, Hal Dunlap, Martin J Reed, Milton Tenenbein, Terry P KlassenAbstract:Objectives The Ottawa Ankle Rules (OAR) have been found to be 100% sensitive in adult patients with Ankle injuries, and application of the OAR has resulted in a 28% reduction in the number of x-rays ordered. The objectives of this study were to determine the sensitivity and specificity of the OAR in children and to determine the potential change in x-ray utilization. Methods Children, aged 2-16 years, presenting to the EDs of two children's hospitals, with an Ankle injury in the previous 48 hours, were enrolled. All patients were assessed by either staff physicians or fellows. X-rays were ordered according to standard clinical practice. Prior to reviewing x-rays, the physical examination was recorded on a standardized form. Positive outcomes (clinically significant) were defined as fractures with fragments > or =3 mm. Patients not x-rayed and asymptomatic at five to seven days postinjury were considered to have no significant fracture. Results Six hundred seventy patients were enrolled. The OAR were 100% sensitive (95% CI = 95% to 100%) for significant Ankle fractures, with a specificity of 24% (95% CI = 20% to 28%). The OAR were 100% sensitive (95% CI = 82% to 100%) for the midfoot, with a specificity of 36% (95% CI = 29% to 43%). If the OAR had been followed, there would have been a reduction of Ankle x-rays by 16% and foot x-rays by 29% without missing any clinically significant fracture. However, analysis of the two hospitals showed that if the Rules had been applied, one would have a reduction in x-rays, while the other center would have an increase. Conclusions This study demonstrates the OAR to be sensitive for detecting clinically significant (> or =3 mm) Ankle and midfoot fractures in children. The application of these Rules may reduce the number of x-rays ordered. A further study is required to determine the effect of using the OAR in clinical practice.
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Ottawa Ankle Rules
Canadian Family Physician, 1996Co-Authors: Ian G StiellAbstract:The Ottawa Ankle rule project demonstrated that more than 95% of patients with Ankle injuries had radiographic examinations but that 85% of the films showed no fractures. A group of Ottawa emergency physicians developed two Rules to identify clinically important fractures of the malleoli and the midfoot. Use of these Rules reduced radiographic examinations by 28% for the Ankle and 14% for the foot.
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cost effectiveness analysis of the Ottawa Ankle Rules
Annals of Emergency Medicine, 1995Co-Authors: Aslam H Anis, Ian G Stiell, David G Stewart, Andreas LaupacisAbstract:Abstract Study objective: To conduct an incremental cost-effectiveness analysis of implementation of the Ottawa Ankle Rules in emergency departments in the United States and Canada. Design: A decision analytic approach to technology assessment. Clinical decision Rules that allow physicians to be more selective in their use of radiography were compared with current practice in a decision analytic model. Setting: A university hospital adult ED. Participants: ED physicians instructed in the use of the Ottawa Ankle Rules for adult patients with Ankle injury. Results: Radiography, waiting time, lost productivity, and medicolegal costs were calculated. In the United States, the savings varied between US$614,226 and US$3,145,910 per 100,000 patients, depending on the charge rate for radiography. In Ontario, Canada, the total savings were CAN$730,145 per 100,000 patients. One- and two-way sensitivity analyses that varied the rate of missed fractures, cost of radiography, probability of lawsuits, and cost of lawsuits did not change the results substantially. Conclusion: Implementation of the Ottawa Ankle Rules would result in significant savings of health care dollars despite the cost of missed fractures including litigation costs. [Anis AH, Stiell IG, Stewart DG, Laupacis A: Cost-effectiveness analysis of the Ottawa Ankle Rules. Ann Emerg Med October 1995;26:422-428.]
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multicentre trial to introduce the Ottawa Ankle Rules for use of radiography in acute Ankle injuries multicentre Ankle rule study group
BMJ, 1995Co-Authors: Ian G Stiell, Andreas Laupacis, George Wells, Robert J Brison, Richard Verbeek, K Vandemheen, C D NaylorAbstract:Abstract Objective: To assess the feasibility and impact of introducing the Ottawa Ankle Rules to a large number of physicians in a wide variety of hospital and community settings over a prolonged period of time. Design: Multicentre before and after controlled clinical trial. Setting: Emergency departments of eight teaching and community hospitals in Canadian communities (population 10000 to 3000000). Subjects: All 12777 adults (6288 control, 6489 intervention) seen with acute Ankle injuries during two 12 month periods before and after the intervention. Intervention: More than 200 physicians of varying experience were taught to order radiography according to the Ottawa Ankle Rules. Main outcome measures: Referral for Ankle and foot radiography. Results: There were significant reductions in use of Ankle radiography at all eight hospitals and within a priori subgroups: for all hospitals combined 82.8% control v 60.9% intervention (P Conclusions: Introduction of the Ottawa Ankle Rules proved to be feasible in a large variety of hospital and community settings. Use of the Rules over a prolonged period of time by many physicians of varying experience led to a decrease in Ankle radiography, waiting times, and costs without an increased rate of missed fractures. The multiphase methodological approach used to develop and implement these Rules may be applied to other clinical problems.
