Cost-Effectiveness of Strategies for Diagnosing Pulmonary Embolism Among Emergency Department Patients Presenting With Undifferentiated Symptoms

Abstract

Objective Symptoms associated with pulmonary embolism (PE) can be nonspecific and similar to many competing diagnoses, leading to excessive costly testing and treatment as well as missed diagnoses. Objective studies are essential for diagnosis. This study evaluates the cost-effectiveness of different diagnostic strategies in an Emergency Department (ED) for patients presenting with undifferentiated symptoms suggestive of PE. Methods Using a probabilistic decision model, we evaluated the incremental costs and effectiveness (quality-adjusted life years (QALYs) gained) of 60 testing strategies for five patient pretest categories (distinguished by Wells score (High, Moderate, or Low) and whether deep venous thrombosis (DVT) is clinically suspected). We performed deterministic and probabilistic sensitivity analyses. Results In the base case, for all patient pretest categories, the most cost-effective diagnostic strategy is to use an initial ELISA D-dimer test, followed by compression ultrasound (CUS) of the lower extremities if the D-dimer is above a specified cutoff. The level of the preferred cutoff varies with the Wells pretest category and whether a DVT is clinically suspected. D-dimer cutoffs higher than the current recommended cutoff were often preferred for even Moderate and High Wells category patients. CUS accuracy had to fall below commonly cited levels in the literature before it was not part of a preferred strategy. Conclusions When PE is suspected in the ED, use of an ELISA D-dimer assay, often at cutoffs higher than those currently in use (for patients in whom DVT is not clinically suspected), followed by CUS as appropriate, can reduce costs and improve outcomes.

A New D-dimer Cutoff Value to Improve the Exclusion of Deep Vein Thrombosis in Cancer Patients

“…The new cutoff minimize radiation exposure by eliminating unnecessary scans, thus the slightly reduced sensitivity could be neglected. Similarly, other reports identified that base lines of D-dimer were higher in the elderly (Smith-Bindman et al, 2009;Duriseti et al, 2010;Kabrhel et al, 2010).…”

Diagnostic Strategies Incorporating Computed Tomography Angiography for Pulmonary Embolism

“…5,29,[40][41][42] Two studies were excluded because they were simply cost analyses and as such did not consider outcomes associated with each test. 34,35 All studies incorporated clinical probability assessment. 34,35 All studies incorporated clinical probability assessment.…”

“…20,[33][34][35][36] The direct costs reported in the study by Ward et al 33 were extracted from Medicare data, and professional fees were taken from the National Physician Fee Schedule. 20,[33][34][35][36] The direct costs reported in the study by Ward et al 33 were extracted from Medicare data, and professional fees were taken from the National Physician Fee Schedule.…”

Clinical and Demographic Predictors of Acute Pulmonary Embolism in Central Africa Using 64-Rows Multi-Detector Computed Tomography Angiography

“…The relevance of obesity with regards to PE was widely reported by some European and American published series (Heit et al, 2010;Duriseti et al, 2010;Goldhaber et al, 1983;Goldhaber, 2010). For Goldhaber et al (1983Goldhaber et al ( , 2010, obesity is an important long-term factor for significant PE at autopsy, and maintaining lower weight might decrease the risk of pulmonary embolism.…”