Articles
7 February 2006

Appropriateness of Diagnostic Management and Outcomes of Suspected Pulmonary Embolism

Publication: Annals of Internal Medicine
Volume 144, Number 3

Abstract

Background:

International guidelines include several strategies for diagnosing pulmonary embolism with confidence, but little is known about how these guidelines are implemented in routine practice.

Objective:

To evaluate the appropriateness of diagnostic management of suspected pulmonary embolism and the relationship between diagnostic criteria and outcome.

Design:

Prospective cohort study with a 3-month follow-up.

Setting:

116 emergency departments in France and 1 in Belgium.

Patients:

1529 consecutive outpatients with suspected pulmonary embolism.

Measurements:

Appropriateness of diagnostic criteria according to international guidelines; incidence of thromboembolic events during follow-up.

Results:

Diagnostic management was inappropriate in 662 (43%) patients: 36 of 429 (8%) patients with confirmed pulmonary embolism and 626 of 1100 (57%) patients in whom pulmonary embolism was ruled out. Independent risk factors for inappropriate management were age older than 75 years (adjusted odds ratio, 2.27 [95% CI, 1.48 to 3.47]), known heart failure (odds ratio, 1.53 [CI, 1.11 to 2.12]), chronic lung disease (odds ratio, 1.39 [CI, 1.00 to 1.94]), current or recent pregnancy (odds ratio, 5.92 [CI, 1.81 to 19.30]), currently receiving anticoagulant treatment (odds ratio, 4.57 [CI, 2.51 to 8.31]), and the lack of a written diagnostic algorithm and clinical probability scoring in the emergency department (odds ratio, 2.54 [CI, 1.51 to 4.28]). Among patients who did not receive anticoagulant treatment, 44 had a thromboembolic event during follow-up: 5 of 418 (1.2%) patients who received appropriate management and 39 of 506 (7.7%) patients who received inappropriate management (absolute risk difference, 6.5 percentage points [CI, 4.0 to 9.1 percentage points]; P < 0.001). Inappropriateness was independently associated with thromboembolism occurrence (adjusted odds ratio, 4.29 [CI, 1.45 to 12.70]).

Limitations:

This was an observational study without evaluation of the risk for overdiagnosis.

Conclusions:

Diagnostic management that does not adhere to guidelines is frequent and harmful in patients with suspected pulmonary embolism. Several risk factors for inappropriateness constitute useful findings for subsequent interventions.
*For members of the EMDEPU Study Group, see the Appendix.

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Comments

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Herman MA Hofstee 15 February 2006
Appropriatness of excluding pulmonary embolism

Dear Sir,

I read with great interest the study of Roy et al. However there is one thing that puzzled me. In figure 2 the authors state that pulmonary embolism (PE) had appropriately been ruled out when a spiral CT and ELISA D-dimer results were negative in the low clinical probability group and that only a negative D-dimer result is sufficient to rule out PE in the high probability group. From basic epidemiology and studies concerning the value of d-dimer in the diagnosis of pulmonary embolism we know that a negative d-dimer provides high certainty for excluding PE (low post-test probability of PE). On the other hand a negative D-dimer in a group with a high a-priori chance is insufficient to rule out PE (higher post-test probability of PE)(1). Could a print error have been occured?

1) Stein PD, Hull RD, Patel KC, Olson RE, Ghali WA, Brant R et al. D- dimer for the exclusion of acute venous thrombosis and pulmonary embolism: a systematic review. Ann Intern Med 2004; 140(8):589-602.

Conflict of Interest:

None declared

Pierre-Marie Roy 14 April 2006
Appropriateness of excluding pulmonary embolism - In response :

Dear sir,

Doctor Hofstee's remark is well-done. We indeed considered as appropriate the exclusion of pulmonary embolism on the basis of a negative ELISA D-dimer test even in patients with a high pretest probability because it was part of the recommendations of the European Society of Cardiology (1). We acknowledge that this criterion for excluding PE is debatable in an Evidence Based Medicine point of view (2). It has been evaluated in large outcomes studies (3, 4) but only a few patients had the combination of a high pretest probability and a negative ELISA D-dimer test.(5) As a general rule, we considered as appropriate all diagnostic strategies that have been selected by international experts. The low rate of recurrent PE in the group of patients with an exclusion strategy based on these recommendations in our study reinforces this choice. Even with such a liberal definition only 57% of the patients underwent an appropriate diagnostic strategy and this was even lower when pulmonary embolism was excluded. Using more stringent criteria for appropriateness would have further reduced the rate of appropriate diagnostic strategies and would have reinforced our conclusion that the diagnosis of pulmonary embolism in clinical practice is far from optimal.

Pierre-Marie Roy and Guy Meyer

Reference

1. Guidelines on diagnosis and management of acute pulmonary embolism. Task Force on Pulmonary Embolism, European Society of Cardiology. Eur Heart J. 2000;21(16):1301-36.

2. Roy PM, Colombet I, Durieux P, Chatellier G, Sors H, Meyer G. Systematic review and meta-analysis of strategies for the diagnosis of suspected pulmonary embolism. Bmj. 2005;331(7511):259.

3. Perrier A, Desmarais S, Miron MJ, et al. Non-invasive diagnosis of venous thromboembolism in outpatients. Lancet. 1999;353(9148):190-5.

4. Perrier A, Roy PM, Aujesky D, et al. Diagnosing pulmonary embolism in outpatients with clinical assessment, D-dimer measurement, venous ultrasound, and helical computed tomography: a multicenter management study. Am J Med. 2004;116(5):291-9.

5. Righini M, Aujesky D, Roy PM, et al. Clinical usefulness of d- dimer depending on clinical probability and cutoff value in outpatients with suspected pulmonary embolism. Arch Intern Med. 2004;164(22):2483-7.

Conflict of Interest:

None declared

Information & Authors

Information

Published In

cover image Annals of Internal Medicine
Annals of Internal Medicine
Volume 144Number 37 February 2006
Pages: 157 - 164

History

Published online: 7 February 2006
Published in issue: 7 February 2006

Keywords

Authors

Affiliations

Pierre-Marie Roy, MD, PhD
From Centre Hospitalier Universitaire, Angers, France; Hôpital Européen Georges Pompidou, Paris, France; Centre Hospitalier Général, Argenteuil, France; Cliniques Universitaires Saint Luc, Brussels, Belgium; Centre Hospitalier Universitaire, Grenoble, France; and Centre Hospitalier Nord Deux-Sèvres, Thouars, France.
Guy Meyer, MD
From Centre Hospitalier Universitaire, Angers, France; Hôpital Européen Georges Pompidou, Paris, France; Centre Hospitalier Général, Argenteuil, France; Cliniques Universitaires Saint Luc, Brussels, Belgium; Centre Hospitalier Universitaire, Grenoble, France; and Centre Hospitalier Nord Deux-Sèvres, Thouars, France.
Bruno Vielle, MD, PhD
From Centre Hospitalier Universitaire, Angers, France; Hôpital Européen Georges Pompidou, Paris, France; Centre Hospitalier Général, Argenteuil, France; Cliniques Universitaires Saint Luc, Brussels, Belgium; Centre Hospitalier Universitaire, Grenoble, France; and Centre Hospitalier Nord Deux-Sèvres, Thouars, France.
Catherine Le Gall, MD
From Centre Hospitalier Universitaire, Angers, France; Hôpital Européen Georges Pompidou, Paris, France; Centre Hospitalier Général, Argenteuil, France; Cliniques Universitaires Saint Luc, Brussels, Belgium; Centre Hospitalier Universitaire, Grenoble, France; and Centre Hospitalier Nord Deux-Sèvres, Thouars, France.
Franck Verschuren, MD
From Centre Hospitalier Universitaire, Angers, France; Hôpital Européen Georges Pompidou, Paris, France; Centre Hospitalier Général, Argenteuil, France; Cliniques Universitaires Saint Luc, Brussels, Belgium; Centre Hospitalier Universitaire, Grenoble, France; and Centre Hospitalier Nord Deux-Sèvres, Thouars, France.
Françoise Carpentier, MD
From Centre Hospitalier Universitaire, Angers, France; Hôpital Européen Georges Pompidou, Paris, France; Centre Hospitalier Général, Argenteuil, France; Cliniques Universitaires Saint Luc, Brussels, Belgium; Centre Hospitalier Universitaire, Grenoble, France; and Centre Hospitalier Nord Deux-Sèvres, Thouars, France.
Philippe Leveau, MD
From Centre Hospitalier Universitaire, Angers, France; Hôpital Européen Georges Pompidou, Paris, France; Centre Hospitalier Général, Argenteuil, France; Cliniques Universitaires Saint Luc, Brussels, Belgium; Centre Hospitalier Universitaire, Grenoble, France; and Centre Hospitalier Nord Deux-Sèvres, Thouars, France.
Alain Furber, MD, PhD
From Centre Hospitalier Universitaire, Angers, France; Hôpital Européen Georges Pompidou, Paris, France; Centre Hospitalier Général, Argenteuil, France; Cliniques Universitaires Saint Luc, Brussels, Belgium; Centre Hospitalier Universitaire, Grenoble, France; and Centre Hospitalier Nord Deux-Sèvres, Thouars, France.
for the EMDEPU Study Group*
From Centre Hospitalier Universitaire, Angers, France; Hôpital Européen Georges Pompidou, Paris, France; Centre Hospitalier Général, Argenteuil, France; Cliniques Universitaires Saint Luc, Brussels, Belgium; Centre Hospitalier Universitaire, Grenoble, France; and Centre Hospitalier Nord Deux-Sèvres, Thouars, France.
Acknowledgments: The authors thank the members of the EMDEPU Study Group and Céline Priou for skilled assistance. They also thank the emergency department residents and all of the physicians who contributed to the management of the patients for their invaluable help throughout the study.
Grant Support: By a grant from the clinical research department of Pays de la Loire (Projet régional Hospitalier de Recherche Clinique).
Disclosures: None disclosed.
Corresponding Author: Pierre-Marie Roy, MD, PhD, Service d'Accueil et Traitement des Urgences, Centre Hospitalier Universitaire, 4 rue Larrey, 49033 Angers Cedex 01, France; e-mail, [email protected].
Current Author Addresses: Dr. Roy: Service d'Accueil et Traitement des Urgences, Centre Hospitalier Universitaire, 4 rue Larrey, 49033 Angers Cedex 01, France.
Dr. Meyer: Service de Pneumologie, Hôpital Européen Georges Pompidou, 20 rue Leblanc, 75908 Paris Cedex 15, France.
Dr. Vielle: Département de Statistique, Centre Hospitalier Universitaire, 4 rue Larrey, 49033 Angers Cedex 01, France.
Dr. Le Gall: Service des Urgences, Centre Hospitalier Général, 69 rue du Colonel Prudhon, 95107 Argenteuil, France.
Dr. Verschuren: Département d'Urgence et de Reanimation, Cliniques Universitaires Saint Luc, Université Catholique de Louvain, 10 avenue Hippocrate, B-1200 Bruxelles, Belgium.
Dr. Carpentier: Service d'Accueil et d'Urgences, Hôpital Albert Michallon, CHU Grenoble, 38700 La Tronche, France.
Dr. Leveau: Service des Urgences, Centre Hospitalier Nord Deux-Sèvres, Center de Thouars, 35 Boulevard Auguste Rodin, 79100 Thouars, France.
Dr. Furber: Service de Cardiologie, Centre Hospitalier Universitaire, 4 rue Larrey, 49033 Angers Cedex 01, France.
Author Contributions: Conception and design: P.-M. Roy, C. Le Gall.
Analysis and interpretation of the data: P.-M. Roy, G. Meyer, B. Vielle, C. Le Gall, P. Leveau, A. Furber.
Drafting of the article: P.-M. Roy, G. Meyer.
Critical revision of the article for important intellectual content: G. Meyer, B. Vielle, C. Le Gall, A. Furber.
Final approval of the article: P.-M. Roy, G. Meyer, B. Vielle, C. Le Gall, F. Verschuren, F. Carpentier, P. Leveau, A. Furber.
Provision of study materials or patients: P.-M. Roy, G. Meyer, C. Le Gall, F. Verschuren, F. Carpentier.
Statistical expertise: B. Vielle.
Obtaining of funding: P.-M. Roy.
Administrative, technical, or logistic support: G. Meyer.
Collection and assembly of data: P.-M. Roy, C. Le Gall, F. Verschuren, F. Carpentier, P. Leveau, A. Furber.

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Pierre-Marie Roy, Guy Meyer, Bruno Vielle, et al; for the EMDEPU Study Group*. Appropriateness of Diagnostic Management and Outcomes of Suspected Pulmonary Embolism. Ann Intern Med.2006;144:157-164. [Epub 7 February 2006]. doi:10.7326/0003-4819-144-3-200602070-00003

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