• Mark H Ebell, Mary E Walsh, Tom Fahey, Maggie Kearney, and Christian Marchello.
• Department of Epidemiology and Biostatistics, College of Public Health , University of Georgia, Athens, GA, USA. ebell@uga.edu.
• J Gen Intern Med. 2019 Jul 1; 34 (7): 1304-1313.

BackgroundThe 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.ObjectiveTo 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.DesignMeta-analysis of accuracy, discrimination, and calibration.MethodsWe 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 ResultsTwenty-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.ConclusionsThe 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%.

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