Ruling out pulmonary embolism across different healthcare settings: A systematic review and individual patient data meta-analysis

Abstract

Background The challenging clinical dilemma of detecting pulmonary embolism (PE) in suspected patients is encountered in a variety of healthcare settings. We hypothesized that the optimal diagnostic approach to detect these patients in terms of safety and efficiency depends on underlying PE prevalence, case mix, and physician experience, overall reflected by the type of setting where patients are initially assessed. The objective of this study was to assess the capability of ruling out PE by available diagnostic strategies across all possible settings. Methods and findings We performed a literature search (MEDLINE) followed by an individual patient data (IPD) meta-analysis (MA; 23 studies), including patients from self-referral emergency care (n = 12,612), primary healthcare clinics (n = 3,174), referred secondary care (n = 17,052), and hospitalized or nursing home patients (n = 2,410). Multilevel logistic regression was performed to evaluate diagnostic performance of the Wells and revised Geneva rules, both using fixed and adapted D-dimer thresholds to age or pretest probability (PTP), for the YEARS algorithm and for the Pulmonary Embolism Rule-out Criteria (PERC). All strategies were tested separately in each healthcare setting. Following studies done in this field, the primary diagnostic metrices estimated from the models were the “failure rate” of each strategy—i.e., the proportion of missed PE among patients categorized as “PE excluded” and “efficiency”—defined as the proportion of patients categorized as “PE excluded” among all patients. In self-referral emergency care, the PERC algorithm excludes PE in 21% of suspected patients at a failure rate of 1.12% (95% confidence interval [CI] 0.74 to 1.70), whereas this increases to 6.01% (4.09 to 8.75) in referred patients to secondary care at an efficiency of 10%. In patients from primary healthcare and those referred to secondary care, strategies adjusting D-dimer to PTP are the most efficient (range: 43% to 62%) at a failure rate ranging between 0.25% and 3.06%, with higher failure rates observed in patients referred to secondary care. For this latter setting, strategies adjusting D-dimer to age are associated with a lower failure rate ranging between 0.65% and 0.81%, yet are also less efficient (range: 33% and 35%). For all strategies, failure rates are highest in hospitalized or nursing home patients, ranging between 1.68% and 5.13%, at an efficiency ranging between 15% and 30%. The main limitation of the primary analyses was that the diagnostic performance of each strategy was compared in different sets of studies since the availability of items used in each diagnostic strategy differed across included studies; however, sensitivity analyses suggested that the findings were robust. Conclusions The capability of safely and efficiently ruling out PE of available diagnostic strategies differs for different healthcare settings. The findings of this IPD MA help in determining the optimum diagnostic strategies for ruling out PE per healthcare setting, balancing the trade-off between failure rate and efficiency of each strategy.

Comparison of VTE risk scores in guidelines for VTE diagnosis in nonsurgical hospitalized patients with suspected VTE

“…A recent systematic review compared the capacity of ruling out PE among the Wells, Geneva, YEARS, and PERC scores across different healthcare settings. In the hospitalized healthcare setting, the Wells plus PTP-adjusted D-dimer(sensitivity 95.64%, specificity 39.50%), the Geneva plus PTP-adjusted D-dimer(sensitivity 95.73%, specificity 37.29%), and the YEARS plus PTP-adjusted D-dimer(sensitivity 96.94%, specificity 35.83%) yielded similar diagnostic accuracy [ 27 ]. It was basically consistent with the present results, except that the YEARS was inferior to the other two in the current study.…”

“…Ever since the Wells and Geneva score emerged, their role in the PTP prediction of PE have been externally validated in a series of previous studies [ 2 , 6 , 9 , 27 , 37 ]. The Geneva and Wells have the most(30 times) and third most(28 times) presence frequency of VTE risk elements, as well as highest(4.29) and second highest(4.00) presence frequency per element among all these six scores, respectively.…”

Diagnostischer Algorithmus Lungenarterienembolie

“…Da die PERC Regel in der Literatur teilweise kritisiert wird und in der ESC-Leitlinie bisher keine generelle Empfehlung ausgesprochen wurde [6], wenden wir die PERC-Regel ausschließlich bei Patient:innen mit klinisch sehr niedriger Wahrscheinlichkeit an. Wird die Wahrscheinlichkeit mithilfe des WELLS-Scores bestimmt, empfehlen wir einen konservativen Wert <2 Punkten (Hinweis: in der Literatur erfolgt die Anwendung der PERC-Regel teilweise bis zu einem WELLS-Score von <5 Punkten [14]).…”

Diagnostic Management of Acute Pulmonary Embolism in COVID-19 and Other Special Patient Populations

“…These patients typically reflect more severe and progressive illness with a high VTE risk. As recently highlighted by an individual participant data meta-analysis (IPD-MA), including over 35,000 patients suspected of PE across different healthcare settings, it is relevant to take PE-prevalence in consideration when judging the performance of the different diagnostic strategies in settings with more high-risk patients [ 43 ]. The IPD-MA showed that both failure rate (i.e., false negative result of test) and efficiency became poorer for all currently available diagnostic strategies.…”