CORRESPONDENCE
IS THE GENEVA RULE
USABLE OUTSIDE OF
GENEVA?
To the Editor:
We read with interest the study by
Chagnon et al. (1) on clinical predic-
tion rules in patients with suspected
pulmonary embolism. Although we
admire the authors’ attempts to pro-
duce a standardized prediction rule
for pulmonary embolism, we believe
that there are some flaws in the meth-
ods used that are important to iden-
tify for potential users of this score.
These have come to light since we re-
cently embarked on a prospective
study of pulmonary embolism at
Christchurch Hospital, New Zealand,
in which we compare the Geneva rule
with implicit risk assessment.
First, we would argue that the pres-
ence of an elevated hemidiaphragm
or atelectasis on an isolated chest ra-
diograph is of uncertain importance
and not an entirely objective sign as
suggested, especially if interpreted by
less experienced clinicians, who are
often the first to see such patients.
Second, the Geneva rule is highly de-
pendent on measurement of arterial
blood gases taken while the patient is
breathing room air. As acknowledged
by the authors, this criterion could
not be applied in 29% of their study
sample. Oxygen is often given while
patients are being assessed as part of a
protocol for the treatment of hyp-
oxia. Finally, we are perplexed by the
receiver operating characteristic
(ROC) curves in the Figure. If the
data given in Table 4 are used to re-
construct curve B, then there are sev-
eral errors. The axes may have been
labelled incorrectly as “1 – specificity”
versus “sensitivity,” when calcula-
tions indicate they are plotted the
other way around. Are we to assume
that the same errors have been made
in curve A? Furthermore, there is no
data point corresponding to the high-
probability group (assuming the
graph should be inverted), as the
curves have not been extrapolated to
©2003 by Excerpta Medica Inc.
All rights reserved.
the axes. We also question whether
ROC curves are the best way to illus-
trate the diagnostic utility of noncon-
tinuous data when there are only
three ordered categories.
Despite these issues, we feel that
the Geneva rule represents the best
standardized method of determining
the pretest probability to date, and it
is for this reason that we are seeking to
validate its use in a population in New
Zealand. After comparing the vari-
ability of both the Geneva rule and
the Wells’ score, we have found that
the Wells’ score contains a highly sub-
jective component: “Alternative diag-
nosis less likely than pulmonary em-
bolism” that renders the score highly
variable among users and therefore
offers no advantage over implicit as-
sessment.
Stephen Iles, MRCP
Aidan Hodges
Chris Frampton, PhD
Ian Town, DM
Canterbury Respiratory
Research Group
Christchurch School of Medicine and
Health Sciences
Christchurch Hospital
New Zealand
1. Chagnon I, Bounameaux H, Aujesky D, et
al. Comparison of two clinical prediction
rules and implicit assessment among pa-
tients with suspected pulmonary embolism.
Am J Med. 2002;113:269 –275.
The Reply:
Iles et al. raise several interesting
points about our paper. Indeed, ele-
vated hemidiaphragm and plate-like
atelectasis are not highly specific
when considered singly, but they are
common in patients with proven pul-
monary embolism, and were clearly
associated with the disease in our der-
ivation sample, both in univariate
and multivariate analyses (1). More-
over, in the original database, those
findings—which are easy to recog-
nize, even by less experienced clini-
cians—were recorded by residents in
charge of patients in the emergency
department. In addition, we did ac-
knowledge that the dependence of the
Geneva rule on arterial blood gas
analysis is a limitation.
Regarding the receiver operating
characteristic (ROC) curves, the axes
in part B of the Figure are inverted,
although those in part A are correct.
We apologize to the readers of The
Green Journal for our error and in-
clude the corrected version below
(Figure). However, that error does
not change the information conveyed
by the Figure. Certainly, the absolute
sensitivity and specificity of the two
cutoff points (between low and inter-
mediate-high probability, and low-
intermediate and high probability)
are of no direct clinical use, but anal-
ysis of the area under the ROC curves
allows comparisons of the predictive
accuracy (2), and these areas are un-
changed even after rectifying the axes.
Contrary to Iles et al., we believe that
ROC curve analysis is the most ap-
propriate means of comparing the di-
agnostic accuracy when there are only
three ordered categories. We did not,
however, state that the Geneva score
overridden by implicit judgment was
superior to the Wells’ score, even
though our analyses showed a statis-
tically significant difference. We
wrote: “The Geneva rule with clinical
override was also marginally better
than the Wells’ rule. . . , which al-
ready includes a subjective element.
However, we believe that no conclu-
sion can be drawn from that observa-
tion because the Wells’ score was cal-
culated retrospectively. Indeed, if the
clinicians had had to rely on the
Wells’ score to guide subsequent in-
vestigations, they might have weighed
the likelihood of an alternative diag-
nosis differently.” On behalf of the
authors, I thank Iles et al. for their
useful comments and careful reading
of our work.
Arnaud Perrier, MD
Medical Clinic
Department of Internal Medicine
Geneva University Hospital
Geneva, Switzerland
0002-9343/03/$–see front matter 339