Elsevier

Academic Radiology

Volume 15, Issue 1, January 2008, Pages 3-14
Academic Radiology

Original investigation
Pretest Risk Assessment in Suspected Acute Pulmonary Embolism

https://doi.org/10.1016/j.acra.2007.07.019Get rights and content

Rationale and Objectives

To assess the pretest practices of US clinicians who treat patients with acute pulmonary embolism (PE).

Materials and Methods

We surveyed 855 practicing physicians selected randomly from three professional organizations. We asked participants to estimate how often and by what method they determine the likelihood of PE before they request confirmatory studies. Participants reported their awareness of four published clinical practice guidelines dealing with acute PE and selected options for further diagnostic testing after reviewing clinical data from three hypothetical patients presenting with low, intermediate, and high probability of acute PE.

Results

We received completed surveys from 240 physicians practicing in 44 states. Although most (98.3%) report that they assess pretest probability of PE before testing, slightly more than half do so routinely. A total of 72.5% prefer an unstructured approach to pretest assessment, whereas 22.9% use published prediction rules. Most (93.0%) are aware of at least one published guideline for assessing acute PE, but only 44.2% report using one or more in daily practice. Respondents who use published prediction rules, estimate pretest probability routinely, or use at least one practice guideline were more likely to request additional testing when reviewing a low probability clinical scenario. No differences in testing frequency or preferences were observed for intermediate or high probability clinical scenarios.

Conclusions

The majority of clinicians we surveyed use an unstructured approach when estimating the pretest probability of acute PE. With the exception of low probability scenario, clinicians agreed on testing choices in suspected acute PE, regardless of the method or frequency of pre-test assessment.

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.

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