Healthcare utilization in chronic thromboembolic pulmonary hypertension after acute pulmonary embolism

Abstract

Essentials Diagnostic delay of chronic thromboembolic pulmonary hypertension (CTEPH) is long. We explored healthcare utilisation of patients diagnosed with CTEPH after pulmonary embolism. A large number of physicians were consulted and test results were not always interpreted correctly. Better education and higher awareness of CTEPH may lead to faster diagnosis. SUMMARY: Background The median diagnostic delay of chronic thromboembolic pulmonary hypertension (CTEPH) is 14 months, which may affect prognosis. We aimed to explore the healthcare utilization of patients diagnosed with CTEPH after acute pulmonary embolism (PE), and to identify the causes of diagnostic delay. Methods We collected all data on patient symptoms, medical specialist referrals and ordered diagnostic tests to reconstruct the clinical pathways of 40 patients referred to the VU University Medical Center Amsterdam (VUMC, the Netherlands) for CTEPH treatment. Diagnostic delay was defined as the time between first symptom onset and referral to the VUMC. Correlations of patient-specific characteristics and diagnostic delay were evaluated. Results Patients consulted four (median) different physicians for a median of 13 (interquartile range [IQR] 10-18) consultations before the correct diagnosis was made. The median diagnostic delay was 21 months (IQR 12-49 months). Echocardiographic results suggestive of CTEPH were not always followed by an adequate work-up; most patients were not subjected to ventilation/perfusion scanning. Prior cardiopulmonary comorbidity and recurrent venous thromboembolism were predictors of a longer delay. Conclusion Healthcare utilization in patients before their final CTEPH diagnosis was far from optimal, contributing to a considerable diagnostic delay. Better education and higher awareness of CTEPH among PE caretakers may lead to faster diagnosis.

Quality of initial anticoagulant treatment and risk of CTEPH after acute pulmonary embolism

“…[2] However and remarkably, at least 25% of CTEPH patients do not have a history of confirmed PE [3], the risk profiles for PE and CTEPH differ considerably [4], and in a majority of CTEPH patients with prior PE, signs of CTEPH were already evident on echocardiography and computed tomography pulmonary angiography (CTPA) at the time of the index PE. [5][6][7][8] This latter is suggestive of diagnostic misclassification rather than CTEPH being the consequence of poorly resolved acute symptomatic PE.…”

Why, Whom, and How to Screen for Chronic Thromboembolic Pulmonary Hypertension after Acute Pulmonary Embolism

“…However, the diagnostic delay of CTEPH in current daily practice is longer than 1 year, prohibiting early initiation of therapy. 4,5 Poor health care utilization in the diagnostic process was reported for 40 CTEPH patients who consulted a median of 4 different physicians for 13 consultations before the correct diagnosis was made. 4 Remarkably, this delay has been associated with higher pulmonary artery pressures at diagnosis and a higher risk of all-cause mortality, underlining the potential severity of progressive disease.…”

“…Test/intervention principles 4. Screening test performance: should be appropriate for the purpose, with all key components specific to the test (rather than the screening program) being accurate (e.g., in terms of sensitivity, specificity, and positive predictive value) and reliable or reproducible.…”

Thrombo-Inflammation in Cardiovascular Disease: An Expert Consensus Document from the Third Maastricht Consensus Conference on Thrombosis

“…261 Earlier CTEPH diagnosis and improved patient outcomes can likely be realized by interventions aimed at improving healthcare utilization during follow-up of acute PE, closer attention to signs of CTEPH on standard CT scans performed to diagnose PE and routine evaluation of the presence of CTEPH in the course of PE in all patients. [262][263][264] For the less severe presentations of the post-PE syndrome, application of cardiopulmonary rehabilitation programs may be of great benefit, achieving full recovery in most patients. Newly developed (patient or physician reported) outcome measures should allow comparison of the effects of different treatments, for example reperfusion therapies, on long-term functional outcome.…”