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.
References
- 1.
American College of Emergency Physicians Clinical Policies Committee . Clinical policy: critical issues in the evaluation and management of adult patients presenting with suspected pulmonary embolism. Ann Emerg Med. 2003;41:257-70. [PMID:12548278 ] CrossrefMedlineGoogle Scholar - 2.
Barritt DW ,Jordan SC . Anticoagulant drugs in the treatment of pulmonary embolism. A controlled trial. Lancet. 1960;1:1309-12. [PMID:13797091 ] CrossrefMedlineGoogle Scholar - 3.
Pineda LA ,Hathwar VS ,Grant BJ . Clinical suspicion of fatal pulmonary embolism. Chest. 2001;120:791-5. [PMID:11555511 ] CrossrefMedlineGoogle Scholar - 4.
Linkins LA ,Choi PT ,Douketis JD . Clinical impact of bleeding in patients taking oral anticoagulant therapy for venous thromboembolism: a meta-analysis. Ann Intern Med. 2003;139:893-900. [PMID:14644891 ] LinkGoogle Scholar - 5.
Kline JA ,Johns KL ,Colucciello SA ,Israel EG . New diagnostic tests for pulmonary embolism. Ann Emerg Med. 2000;35:168-80. [PMID:10650235 ] CrossrefMedlineGoogle Scholar - 6.
Chunilal SD ,Eikelboom JW ,Attia J ,Miniati M ,Panju AA ,Simel DL ,et al . Does this patient have pulmonary embolism? JAMA. 2003;290:2849-58. [PMID:14657070 ] CrossrefMedlineGoogle Scholar - 7.
Mountain D . Diagnosing pulmonary embolism: a question of too much choice? Emerg Med (Fremantle). 2003;15:250-62. [PMID:12786647 ] CrossrefMedlineGoogle Scholar - 8.
Miller AC ,Boldy DA . Pulmonary embolism guidelines: will they work? [Editorial]. Thorax. 2003;58:463. [PMID:12775852 ] CrossrefMedlineGoogle Scholar - 9.
Cockcroft DW ,Gault MH . Prediction of creatinine clearance from serum creatinine. Nephron. 1976;16:31-41. [PMID:1244564 ] CrossrefMedlineGoogle Scholar - 10.
British Thoracic Society Standards of Care Committee Pulmonary Embolism Guideline Development Group . British Thoracic Society guidelines for the management of suspected acute pulmonary embolism. Thorax. 2003;58:470-83. [PMID:12775856 ] CrossrefMedlineGoogle Scholar - 11.
Kearon C . Diagnosis of pulmonary embolism. CMAJ. 2003;168:183-94. [PMID:12538548 ] MedlineGoogle Scholar - 12.
Kruip MJ ,Leclercq MG ,van der Heul C ,Prins MH ,Buller HR . Diagnostic strategies for excluding pulmonary embolism in clinical outcome studies. A systematic review. Ann Intern Med. 2003;138:941-51. [PMID:12809450 ] LinkGoogle Scholar - 13. Guidelines on diagnosis and management of acute pulmonary embolism. Task Force on Pulmonary Embolism, European Society of Cardiology. Eur Heart J. 2000;21:1301-36. [PMID:
10952823 ] CrossrefMedlineGoogle Scholar - 14.
Fedullo PF ,Tapson VF . Clinical practice. The evaluation of suspected pulmonary embolism. N Engl J Med. 2003;349:1247-56. [PMID:14507950 ] CrossrefMedlineGoogle Scholar - 15.
Peduzzi P ,Concato J ,Kemper E ,Holford TR ,Feinstein AR . A simulation study of the number of events per variable in logistic regression analysis. J Clin Epidemiol. 1996;49:1373-9. [PMID:8970487 ] CrossrefMedlineGoogle Scholar - 16.
Stein PD ,Terrin ML ,Hales CA ,Palevsky HI ,Saltzman HA ,Thompson BT ,et al . Clinical, laboratory, roentgenographic, and electrocardiographic findings in patients with acute pulmonary embolism and no preexisting cardiac or pulmonary disease. Chest. 1991;100:598-603. [PMID:1909617 ] CrossrefMedlineGoogle Scholar - 17.
Chagnon I ,Bounameaux H ,Aujesky D ,Roy PM ,Gourdier AL ,Cornuz J ,et al . Comparison of two clinical prediction rules and implicit assessment among patients with suspected pulmonary embolism. Am J Med. 2002;113:269-75. [PMID:12361811 ] CrossrefMedlineGoogle Scholar - 18.
Grimshaw JM ,Shirran L ,Thomas R ,Mowatt G ,Fraser C ,Bero L ,et al . Changing provider behavior: an overview of systematic reviews of interventions. Med Care. 2001;39:II2-45. [PMID:11583120 ] CrossrefMedlineGoogle Scholar - 19.
Musset D ,Parent F ,Meyer G ,Martre S ,Girard P ,Leroyer C ,et al . Diagnostic strategy for patients with suspected pulmonary embolism: a prospective multicentre outcome study. Lancet. 2002;360:1914-20. [PMID:12493257 ] CrossrefMedlineGoogle Scholar - 20.
Perrier A ,Roy PM ,Aujesky D ,Chagnon I ,Howarth N ,Gourdier AL ,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;116:291-9. [PMID:14984813 ] CrossrefMedlineGoogle Scholar - 21.
Schoepf UJ ,Goldhaber SZ ,Costello P . Spiral computed tomography for acute pulmonary embolism. Circulation. 2004;109:2160-7. [PMID:15136509 ] CrossrefMedlineGoogle Scholar - 22.
Wells PS ,Anderson DR ,Rodger M ,Stiell I ,Dreyer JF ,Barnes D ,et al . Excluding pulmonary embolism at the bedside without diagnostic imaging: management of patients with suspected pulmonary embolism presenting to the emergency department by using a simple clinical model and d-dimer. Ann Intern Med. 2001;135:98-107. [PMID:11453709 ] LinkGoogle Scholar - 23.
Perrier A ,Desmarais S ,Miron MJ ,deMoerloose P ,Lepage R ,Slosman D ,et al . Non-invasive diagnosis of venous thromboembolism in outpatients. Lancet. 1999;353:190-5. [PMID:9923874 ] CrossrefMedlineGoogle Scholar
Author, Article, and Disclosure Information
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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