Compliance to clinical pathways in the management of suspected pulmonary embolus: are there cost implications?

Rehman, Ata Ur; Yelf, Eric; Pearson, J.W.; Yeo, W. W.

doi:10.1111/imj.13387

Cited by 3 publications

(3 citation statements)

References 18 publications

(18 reference statements)

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“…We did not evaluate patients’ pretest probability for PE as part of this study, which may have led to inclusion of higher risk patients for PE. While D‐dimer testing has been validated for use in patients with a low to moderate pretest probability using an evidence‐based decision rule, 37 prior studies have demonstrated inconsistency of this practice in the clinical setting and so our findings may be more representative of actual clinical practice 38,39 . Our quasi‐experimental study design was used to estimate the causal effect of the intervention and as such may be subject to unmeasured confounding 40 .…”

Section: Limitationsmentioning

confidence: 99%

“…While D-dimer testing has been validated for use in patients with a low to moderate pretest probability using an evidence-based decision rule, 37 prior studies have demonstrated inconsistency of this practice in the clinical setting and so our findings may be more representative of actual clinical practice. 38,39 Our quasi-experimental study design was used to estimate the causal effect of the intervention and as such may be subject to unmeasured confounding. 40 We addressed this limitation using segmented regression analysis of an interrupted time series that included a robust preintervention phase.…”

Section: Limitationsmentioning

confidence: 99%

See 1 more Smart Citation

Effect of Using an Age‐adjusted D‐dimer to Assess for Pulmonary Embolism in Community Emergency Departments

Ghobadi

Lin

Musigdilok

et al. 2020

Academic Emergency Medicine

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Background The objective of this study was to evaluate the effect of changing the laboratory‐reported D‐dimer reference intervals to age‐adjusted reference intervals on the use of advanced chest imaging and 30‐day adverse events among emergency department (ED) encounters. Methods A retrospective interrupted time‐series analysis of ED encounters for patients > 50 years evaluated for suspected pulmonary embolism (PE) from April 2014 to April 2016. The primary outcome was use of advanced diagnostic imaging, and the secondary outcome was 30‐day mortality or PE diagnosis. Secondary analyses also quantified delayed PE diagnoses pre‐ and postintervention. A generalized estimating equation segmented logistic regression model, adjusting for patient and facility characteristics, was used to determine changes in odds of diagnostic imaging and 30‐day mortality or PE diagnoses. Results A total of 10,534 (5,153 pre‐ and 5,381 postimplementation) ED encounters were included. Advanced imaging was obtained in 35.9% of pre‐ versus 33% of postimplementation encounters. Age‐adjusted D‐dimer (AADD) showed a small and nonsignificant decrease in month‐to‐month trends of advanced chest imaging postimplementation (odds ratio [OR] = 0.98, 95% confidence interval [CI] = 0.96 to 1.00). Use of advanced imaging in patients with D‐dimer values lower than 500 ng/mL fibrinogen‐equivalent units (FEU) was similar in the preintervention (5.8%) and postintervention (6.8%) periods. However, imaging was obtained in 30% of patients postintervention with a D‐dimer result less than AADD reference interval , but more than the historical 500 ng/mL FEU reference interval. Implementing an AADD threshold demonstrated no change in the rate of 30‐day adverse events (missed PE or mortality). Conclusion Changing the laboratory‐reported D‐dimer reference intervals for evaluation of PE was not associated with reduction in advanced chest imaging and did not increase 30‐day adverse events. However, there was substantial noncompliance with the age‐adjusted reference intervals in the postintervention period likely blunting the impact of this intervention.

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Section: Limitationsmentioning

confidence: 99%

Section: Limitationsmentioning

confidence: 99%

Effect of Using an Age‐adjusted D‐dimer to Assess for Pulmonary Embolism in Community Emergency Departments

Ghobadi

Lin

Musigdilok

et al. 2020

Academic Emergency Medicine

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“…Because of nonspecific symptoms, which may suggest another condition, the diagnosis of PE might be challenging in real-life practice. Despite subsequent updates of the clinical guidelines and statements released by international societies dealing with VTE [3,4], the diagnostic pathways in case of suspected APE in everyday practice are still burdened with numerous errors [5][6][7]. Undiagnosed APE leads to death, chronic thromboembolic pulmonary hypertension, disability, and worsening of quality of life.…”

Section: Introductionmentioning

confidence: 99%

In-hospital diagnostic strategies for acute pulmonary embolism — results of a single-center study based on the experience of a multi-profile clinical hospital

Szymańska

Kurzyna²,

Kułak³

et al. 2022

Acta Angiologica

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Introduction: Acute pulmonary embolism (APE) is the most severe clinical presentation of venous thromboembolism (VTE) and inappropriate diagnostic strategies of APE lead to death or chronic thromboembolic pulmonary hypertension.Material and methods: In prospective manner we followed patients admitted to a tertiary clinical center with APE proven with CT scan within the period of 24 months. We assessed diagnostic strategies of APE in different clinical departments of Polish multi-profile hospital and their association with prognosis. Results: A total number of 178 patients with APE were enrolled in the study, of which 56 patients were diagnosed with APE in the emergency department (ED), 42 in cardiology departments, and 80 in other departments. No significant differences in diagnostic strategies between departments were found. Adherence to ESC guidelines was 56.1% and it was similar in compared departments (p = 0.648). The in-hospital mortality rate was 6.7%. In the 6 month follow-up period 18.1% of the studied died. Coronary artery disease (p = 0.002), cancer (p = 0.032), serious medical condition (p = 0.047), altered mental status (p = 0.032), CRP (p = 0.006), and hemoglobin (p = 0.023) were identified as predictors of clinical deterioration. Risk factors for in-hospital and 6-month mortality were congestive heart failure, serious medical condition, and systolic blood pressure (p < 0.05). Immobility over 3 days and cancer were also identified as predictors of death within 6 months (p < 0.001). There was no association between the type of the department, clinical deterioration, in-hospital, and 6-month mortality. Conclusion: There is no difference in APE management and prognosis in different profile departments.

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Age-adjusted D-dimer thresholds in the investigation of suspected pulmonary embolism: A retrospective evaluation in patients ages 50 and older using administrative data

Senior

Burles

Wang

et al. 2018

CJEM

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CLINICIAN'S CAPSULE What is known about the topic? Age-adjusted D-dimer thresholds have been proposed to improve specificity of diagnostic testing for thromboembolism in patients ages 50 and over. What did this study ask? What is the diagnostic accuracy of an age-adjusted D-dimer threshold in a population of patients undergoing investigations for suspected pulmonary embolism (PE)? What did this study find? Age-adjusted D-dimer cut-offs improved specificity but at the expense of a slightly higher risk of missed PE. Why does this study matter to clinicians? Use of age adjusted D-dimer thresholds, in combination with validated risk scores, may reduce CT utilization in older patients.

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Compliance to clinical pathways in the management of suspected pulmonary embolus: are there cost implications?

Cited by 3 publications

References 18 publications

Effect of Using an Age‐adjusted D‐dimer to Assess for Pulmonary Embolism in Community Emergency Departments

Effect of Using an Age‐adjusted D‐dimer to Assess for Pulmonary Embolism in Community Emergency Departments

In-hospital diagnostic strategies for acute pulmonary embolism — results of a single-center study based on the experience of a multi-profile clinical hospital

Age-adjusted D-dimer thresholds in the investigation of suspected pulmonary embolism: A retrospective evaluation in patients ages 50 and older using administrative data

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