Original investigationPretest Risk Assessment in Suspected Acute Pulmonary Embolism
Section snippets
Study Population and Sample Size
The Joint Committee on Clinical Investigation, our institutional review board, approved the study design and survey instrument, waiving the need for informed consent. We selected emergency medicine specialists, pulmonologists, and general internists as our survey population as we felt that these groups’ physicians would commonly encounter PE in their clinical practices. As well, we felt that having three distinct groups of physicians would improve the generalizability of our study and would
Survey Responses
Of the 855 physicians selected, 32 notified us that they were retired from practice or were no longer seeing patients, and 17 surveys were undeliverable and returned by the post office. Of the 806 potentially eligible participants, we received completed surveys from 240 physicians (29.8%) practicing in 44 states. Physician and practice characteristics have been summarized previously (27, 28).
Method and Frequency of Pretest Assessment
All but four respondents, 98.3%, reported that they assess the pretest probability of PE before
Discussion
The determination of pretest likelihood based on clinical parameters has been recommended broadly for the accurate and cost-effective evaluation of suspected acute PE. Yet, our study demonstrates that approximately three of four clinicians who responded to our questionnaire do not use published prediction rules to stratify their patients into low-, intermediate-, and high-probability categories. Instead, most prefer an unstructured method to stratify patients into two or three probability
Acknowledgments
The authors thank Evanus Forrester for her generous assistance in preparing the mailing lists; Chris O’Keefe, BS, for preparation of the response database; and Sheila C. Weiss, RD, for her assistance in preparing and mailing the surveys.
References (52)
- et al.
The application of a Dutch consensus diagnostic strategy for pulmonary embolism in clinical practice
Neth J Med
(2001) - et al.
A structured clinical model for predicting the probability of pulmonary embolism
Am J Med
(2003) - et al.
Prospective validation of Wells Criteria in the evaluation of patients with suspected pulmonary embolism
Ann Emerg Med
(2004) - et al.
Usefulness of clinical prediction rules for the diagnosis of venous thromboembolism: a systematic review
Am J Med
(2004) Before diagnostic testing for pulmonary embolism: estimating the prior probability of disease
Am J Med
(2003)- et al.
The interobserver reliability of pretest probability assessment in patients with suspected pulmonary embolism
Thromb Res
(2005) - et al.
Response rates to mail surveys published in medical journals
J Clin Epidemiol
(1997) - et al.
CT Pulmonary angiography is the first-line imaging test for acute pulmonary embolism: a survey of US clinicians
Acad Radiol
(2006) - et al.
Scanning systems and protocols used during imaging for acute pulmonary embolism how much do our clinical colleagues know?
Acad Radiol
(2006) - et al.
Inadequate use of asthma medication in the United States: results of the asthma in America national population survey
J Allergy Clin Immunol
(2002)
Attitudes of physicians toward objective measures of airway function in asthma
Am J Med
Evaluation and treatment of patients with severely elevated blood pressure in academic emergency departments: a multicenter study
Ann Emerg Med
Noncompliance with “best practices” may be justifiable
Lancet
Omission bias and decision making in pulmonary and critical care medicine
Chest
Venous thromboembolism
Am Rev Respir Dis
Cost-effective diagnosis of deep vein thrombosis and pulmonary embolism
Thromb Haemost
Clinical practiceThe evaluation of suspected pulmonary embolism
N Engl J Med
Value of the ventilation/perfusion scan in acute pulmonary embolism. Results of the prospective investigation of pulmonary embolism diagnosis (PIOPED). The PIOPED Investigators
JAMA
Comparison of 3 clinical models for predicting the probability of pulmonary embolism
Medicine
Assessing clinical probability of pulmonary embolism in the emergency ward: a simple score
Arch Intern Med
Derivation of a simple clinical model to categorize patients probability of pulmonary embolism: increasing the models utility with the SimpliRED D-dimer
Thromb Haemost
CT pulmonary angiography: a comparative analysis of the utilization patterns in emergency department and hospitalized patients between 1998 and 2003
AJR Am J Roentgenol
Impact of spiral computed tomography on the diagnosis of pulmonary embolism in a community hospital setting
Respiration
Use of a clinical model for safe management of patients with suspected pulmonary embolism
Ann Intern Med
Accuracy of clinical assessment in the diagnosis of pulmonary embolism
Am J Resp Crit Care Med
External validation and comparison of recently described prediction rules for suspected pulmonary embolism
Curr Opin Pulm Med
Cited by (19)
Role of D-dimer assays in the diagnostic evaluation of pulmonary embolism
2015, American Journal of the Medical SciencesCitation Excerpt :The International Cooperative Pulmonary Embolism Registry (ICOPER) study that reviewed data on more than 2,000 patients with confirmed PE also reported chest x-ray infiltrates in 17% of patients.18 Unfortunately, many physicians are unaware of these findings, and a recent assessment of clinical practice found physicians significantly less likely to order diagnostic follow-up testing in low- and intermediate-risk patients who presented with infiltrates on chest x-ray.19 The current recommendations in the diagnostic algorithm for PE incorporate a combination of clinical decision-making rules6,7 and biomarkers.20–22
Emergency department variation in utilization and diagnostic yield of advanced radiography in diagnosis of pulmonary embolus
2014, Journal of Emergency MedicineCitation Excerpt :Multiple validated clinical decision rules (CDRs) can help guide physicians' decision of who needs a CT scan (15–18). However, studies have shown variable physician use of these rules to risk-stratify patients, along with high use of CT in low-risk patients with negative D-dimer results (19,20). No studies, to our knowledge, have examined the variability of approach to ruling out PE within groups of emergency physicians.
Probability Scores and Diagnostic Algorithms in Pulmonary Embolism: Are They Followed in Clinical Practice?
2014, Archivos de BronconeumologiaIs a V/Q scan based algorithm correctly used to diagnose acute pulmonary embolism? A daily practice survey
2011, Thrombosis ResearchCitation Excerpt :In both studies the observation was made that physicians do not adhere to guidelines for the diagnostic management of PE. In addition, Weiss et al. [17] revealed that clinicians treating patients with acute PE prefer an unstructured approach as opposed to published algorithms to estimate pre-test probability. Of note, in the study of Arnason et al. [16] 29% of the patients with a non-high probability V/Q scan did not undergo further imaging.
Current approach to the diagnosis of acute nonmassive pulmonary embolism
2011, ChestCitation Excerpt :Ultimately, the CDR used is of less importance than the principle that the clinician's PTP must be determined before further diagnostic testing is performed. Clinicians who use formal rules for the assessment of PTP are more likely to follow published practice guidelines for the evaluation and treatment of PE.9 Additionally, the absence of a formal assessment has been associated with inappropriate management and worse outcome in patients with suspected PE.10
Investigating suspected acute pulmonary embolism - what are hospital clinicians thinking?
2009, Clinical Radiology