Safety of the Combination of <scp>PERC</scp> and <scp>YEARS</scp> Rules in Patients With Low Clinical Probability of Pulmonary Embolism: A Retrospective Analysis of Two Large European Cohorts

Gorlicki, Judith; Penaloza, Andréa; Germeau, Boris; Moumneh, Thomas; Philippon, Anne-Laure; Truchot, Jennifer; Douillet, Delphine; Steinier, Charlotte; Soulié, Caroline; Bloom, Ben; Cachanado, Marine; Roy, Pierre‐Marie; Freund, Yonathan

doi:10.1111/acem.13508

Cited by 7 publications

(6 citation statements)

References 23 publications

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“…This particular CDM tool reduces the number of CTPA studies performed if the d-dimer is below a certain threshold and certain criteria are met ( Table 1). An interesting recent study demonstrated that if PERC was combined with YEARS, the failure rate was very low (0.57% failure rate), and resulted in a CTPA use reduction by 50%, as well as a reduction in d-dimer testing of 35% [21]. Although our study did not directly assess PERC utilization, the fact that we had 10 patients who were PERC negative and still had a CTPA study performed, is concerning for the underutilization of this validated CDM tool.…”

Section: Discussionmentioning

confidence: 99%

Retrospective Analysis of the Computed Tomography Pulmonary Angiogram Utilization Patterns in the Emergency Department

2019

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Objectives Guidelines and high-quality studies recommend using clinical decision-making (CDM) tools over clinical gestalt when evaluating a patient for pulmonary embolism. The purpose of this study is to investigate our computed tomography pulmonary angiogram (CTPA) utilization patterns and identify causal factors. Methods A retrospective cohort study of CTPA studies ordered by emergency physicians in January, April, July, and October 2017 was undertaken. All necessary information to categorize patients by Wells' score, revised Geneva score, and pulmonary embolism rule-out criteria (PERC) was collected. In addition, various bloodwork, chest radiograph, and computed tomography results were collected. This data was analysed by the Pearson chi-square test or Fisher's exact test for categorical data and independent-samples t test for continuous variables. Results A total of 510 CTPA studies were performed, with a mean age was 61.6 and a 50.6% female population. 136 studies (26.7%) failed to appropriately follow any CDM tool. CDM tool failure rate was dependent on whether the study was ordered from a community (14.9%) or tertiary hospital (University of Alberta Hospital, 27.9% and Royal Alexandra Hospital, 24.6%) ( P = .038). Of these 136 studies, 31 were low/moderate risk and the d-dimer was negative. The remainder were either PERC-negative or low/moderate risk without d-dimer performed. The cumulative positive pulmonary embolism rate was 12.5%. With utilization of a CDM tool, the positive pulmonary embolism rate was 15.0%, compared to 5.9% when using gestalt ( P = .026). Conclusions This study confirms a high rate of CDM tool use failure, and a higher positive CTPA rate for CDM tools compared to clinical gestalt.

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Section: Discussionmentioning

confidence: 99%

Retrospective Analysis of the Computed Tomography Pulmonary Angiogram Utilization Patterns in the Emergency Department

2019

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“…Combining these different strategies may be the more efficient way to reduce over-testing if it is proven to be safe. In a retrospective study involving 1951 patients who overall had a low probability (3.9% prevalence), combining the PERC rule and the YEARS rule made it possible to significantly reduce the number of CTAs, with a low rate of false negatives: 0.83% (95% CI = 0.51–1.35) [ 79 ]. Freund et al assessed this possibility in a cluster randomized cross-over trial in 18 ED [ 6 ].…”

Section: The Strategies Designed To Limit the Use Of Imaging Testsmentioning

confidence: 99%

How to Combat Over-Testing for Patients Suspected of Pulmonary Embolism: A Narrative Review

et al. 2023

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The diagnosis of PE remains difficult in 2023 because the signs and symptoms are not sensible nor specific. The consequences of potential diagnostic errors can be dramatic, whether by default or by excess. Furthermore, the achievement of a simple diagnostic strategy, based on clinical probability assessment, D-dimer measurement and computed tomography pulmonary angiography (CTPA) leads to a new challenge for PE diagnosis: over-testing. Indeed, since the 2000s, the wide availability of CTPA resulted in a major increase in investigations with a mod I confirm erate increase in PE diagnosis, without any notable improvement in patient outcomes. Quite the contrary, the complications of anticoagulation for PE increased significantly, and the long-term consequences of imaging diagnostic radiation is an important concern, especially the risk of breast cancer for young women. As a result, several strategies have been proposed to fight over-testing. They are mostly based on defining a subgroup of patients for whom no specific exam should be required to rule-out PE and adjusting the D-dimer cutoff to allow the exclusion of PE without performing CTPA. This narrative review presents the advantages and limitations of these different strategies as well as the perspective in PE diagnosis.

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“…The D-dimer threshold of 1,000 µg/L was used in cases of low clinical probability, while the classical threshold of 500 µg/L is used for moderate clinical probability, avoiding 16% of CTPA compared with the classical strategy and a failure rate of 0% (95% CI: 0-2.9%). 63 Recently, a new clinical probability score was derived. The 4PEPS merged all previous strategies with overtesting: ruling out PE on clinical criteria alone (PERC strategy), using 1,000 µg/L as the D-dimer cut-off in cases of low CP (PEGeD and YEARS strategy), using an age-adjusted D-dimer cut-off in cases of moderate CP (►Table 1).…”

Section: Strategies Against Overtestingmentioning

confidence: 99%

Suspected Acute Pulmonary Embolism: Gestalt, Scoring Systems, and Artificial Intelligence

Douillet

Roy

Penaloza

2021

Semin Respir Crit Care Med

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Pulmonary embolism (PE) remains a diagnostic challenge in 2021. As the pathology is potentially fatal and signs and symptoms are nonspecific, further investigations are classically required. Based on the Bayesian approach, clinical probability became the keystone of the diagnostic strategy to rule out PE in the case of a negative testing. Several clinical probability assessment methods are validated: gestalt, the Wells score, or the revised Geneva score. While the debate persists as to the best way to assess clinical probability, its assessment allows for the good interpretation of the investigation results and therefore directs the correct diagnostic strategy. The wide availability of computed tomography pulmonary angiography (CTPA) resulted in a major increase in investigations with a moderate increase in diagnosis, without any notable improvement in patient outcomes. This leads to a new challenge for PE diagnosis which is the limitation of the number of testing for suspected PE. We review different strategies recently developed to achieve this goal. The last challenge concerns the implementation in clinical practice. Two approaches are developed: simplification of the strategies versus the use of digital support tools allowing more sophisticated strategies. Artificial intelligence with machine-learning algorithms will probably be a future tool to guide the physician in this complex approach concerning acute PE suspicion.

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Safety of the Combination of PERC and YEARS Rules in Patients With Low Clinical Probability of Pulmonary Embolism: A Retrospective Analysis of Two Large European Cohorts

Abstract: The combination of PERC then YEARS was associated with a low risk of PE diagnostic failure and would have resulted in a relative reduction of almost half of CTPA.

Cited by 7 publications

References 23 publications

Retrospective Analysis of the Computed Tomography Pulmonary Angiogram Utilization Patterns in the Emergency Department

Retrospective Analysis of the Computed Tomography Pulmonary Angiogram Utilization Patterns in the Emergency Department

How to Combat Over-Testing for Patients Suspected of Pulmonary Embolism: A Narrative Review

Suspected Acute Pulmonary Embolism: Gestalt, Scoring Systems, and Artificial Intelligence

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