Developing a framework for evidence-based grading and assessment of predictive tools for clinical decision support

Background: Clinical predictive tools quantify contributions of relevant patient characteristics to derive likelihood of diseases or predict clinical outcomes. When selecting predictive tools for implementation at clinical practice or for recommendation in clinical guidelines, clinicians are challenged with an overwhelming and ever-growing number of tools, most of which have never been implemented or assessed for comparative effectiveness. To overcome this challenge, we have developed a conceptual framework to Grade and Assess Predictive tools (GRASP) that can provide clinicians with a standardised, evidence-based system to support their search for and selection of efficient tools. Methods: A focused review of the literature was conducted to extract criteria along which tools should be evaluated. An initial framework was designed and applied to assess and grade five tools: LACE Index, Centor Score, Well's Criteria, Modified Early Warning Score, and Ottawa knee rule. After peer review, by six expert clinicians and healthcare researchers, the framework and the grading of the tools were updated. Results: GRASP framework grades predictive tools based on published evidence across three dimensions: 1) Phase of evaluation; 2) Level of evidence; and 3) Direction of evidence. The final grade of a tool is based on the highest phase of evaluation, supported by the highest level of positive evidence, or mixed evidence that supports a positive conclusion. Ottawa knee rule had the highest grade since it has demonstrated positive post-implementation impact on healthcare. LACE Index had the lowest grade, having demonstrated only pre-implementation positive predictive performance. Conclusion: GRASP framework builds on widely accepted concepts to provide standardised assessment and evidence-based grading of predictive tools. Unlike other methods, GRASP is based on the critical appraisal of published evidence reporting the tools' predictive performance before implementation, potential effect and usability during implementation, and their post-implementation impact. Implementing the GRASP framework as an online platform can enable clinicians and guideline developers to access standardised and structured reported evidence of existing predictive tools. However, keeping GRASP reports up-to-date would require updating tools' assessments and grades when new evidence becomes available, which can only be done efficiently by employing semi-automated methods for searching and processing the incoming information.