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Biciusca T, Gruenewald LD, Martin SS, Gotta J, Mahmoudi S, Eichler K, Booz C, Salbach C, Müller-Hennessen M, Biener M, Yildirim M, Milles B, Sommer CM, Vogl TJ, Giannitsis E, Koch V. Optimizing resource allocation: Cost-effectiveness of specified D-dimer cut-offs in cancer patients with suspected venous thromboembolism. J Thromb Thrombolysis 2024:10.1007/s11239-024-03000-2. [PMID: 38762707 DOI: 10.1007/s11239-024-03000-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/05/2024] [Indexed: 05/20/2024]
Abstract
An accurate diagnosis of venous thromboembolism (VTE) is crucial, given the potential for high mortality in undetected cases. Strategic D-dimer testing may aid in identifying low-risk patients, preventing overdiagnosis and reducing imaging costs. We conducted a retrospective, comparative analysis to assess the potential cost savings that could be achieved by adopting different approaches to determine the most effective D-dimer cut-off value in cancer patients with suspected VTE, compared to the commonly used rule-out cut-off level of 0.5 mg/L. The study included 526 patients (median age 65, IQR 55-75) with a confirmed cancer diagnosis who underwent D-dimer testing. Among these patients, the VTE prevalence was 29% (n = 152). Each diagnostic strategy's sensitivity, specificity, negative likelihood ratio (NLR), as well as positive likelihood ratio (PLR), and the proportion of patients exhibiting a negative D-dimer test result, were calculated. The diagnostic strategy that demonstrated the best balance between specificity, sensitivity, NLR, and PLR, utilized an inverse age-specific cut-off level for D-dimer [0.5 + (66-age) × 0.01 mg/L]. This method yielded a PLR of 2.9 at a very low NLR for the exclusion of VTE. We observed a significant cost reduction of 4.6% and 1.0% for PE and DVT, respectively. The utilization of an age-adjusted cut-off [patient's age × 0.01 mg/L] resulted in the highest cost savings, reaching 8.1% for PE and 3.4% for DVT. Using specified D-dimer cut-offs in the diagnosis of VTE could improve economics, considering the limited occurrence of confirmed cases among patients with suspected VTE.
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Affiliation(s)
- Teodora Biciusca
- Department of Diagnostic and Interventional Radiology, Goethe University Frankfurt, University Hospital, Frankfurt Am Main, Germany.
| | - Leon D Gruenewald
- Department of Diagnostic and Interventional Radiology, Goethe University Frankfurt, University Hospital, Frankfurt Am Main, Germany
| | - Simon S Martin
- Department of Diagnostic and Interventional Radiology, Goethe University Frankfurt, University Hospital, Frankfurt Am Main, Germany
| | - Jennifer Gotta
- Department of Diagnostic and Interventional Radiology, Goethe University Frankfurt, University Hospital, Frankfurt Am Main, Germany
| | - Scherwin Mahmoudi
- Department of Diagnostic and Interventional Radiology, Goethe University Frankfurt, University Hospital, Frankfurt Am Main, Germany
| | - Katrin Eichler
- Department of Diagnostic and Interventional Radiology, Goethe University Frankfurt, University Hospital, Frankfurt Am Main, Germany
| | - Christian Booz
- Department of Diagnostic and Interventional Radiology, Goethe University Frankfurt, University Hospital, Frankfurt Am Main, Germany
| | - Christian Salbach
- Department of Cardiology, Angiology, and Pulmonology, University of Heidelberg, University Hospital, Heidelberg, Germany
| | - Matthias Müller-Hennessen
- Department of Cardiology, Angiology, and Pulmonology, University of Heidelberg, University Hospital, Heidelberg, Germany
| | - Moritz Biener
- Department of Cardiology, Angiology, and Pulmonology, University of Heidelberg, University Hospital, Heidelberg, Germany
| | - Mustafa Yildirim
- Department of Cardiology, Angiology, and Pulmonology, University of Heidelberg, University Hospital, Heidelberg, Germany
| | - Barbara Milles
- Department of Cardiology, Angiology, and Pulmonology, University of Heidelberg, University Hospital, Heidelberg, Germany
| | - Christof M Sommer
- Department of Diagnostic and Interventional Radiology, University of Heidelberg, University Hospital, Heidelberg, Germany
| | - Thomas J Vogl
- Department of Diagnostic and Interventional Radiology, Goethe University Frankfurt, University Hospital, Frankfurt Am Main, Germany
| | - Evangelos Giannitsis
- Department of Cardiology, Angiology, and Pulmonology, University of Heidelberg, University Hospital, Heidelberg, Germany
| | - Vitali Koch
- Department of Diagnostic and Interventional Radiology, Goethe University Frankfurt, University Hospital, Frankfurt Am Main, Germany
- Department of Cardiology, Angiology, and Pulmonology, University of Heidelberg, University Hospital, Heidelberg, Germany
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Naimi S, Ødegaard KJ, Jenssen KK, Lauritzen PM. Quality of referrals for lower extremity ultrasonography and computed tomography pulmonary angiography and associations with positive findings of venous thromboembolism. Radiography (Lond) 2024; 30:799-805. [PMID: 38493553 DOI: 10.1016/j.radi.2024.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Revised: 02/29/2024] [Accepted: 03/04/2024] [Indexed: 03/19/2024]
Abstract
INTRODUCTION The referral is the basis for radiologists' assessment of modality, protocol and urgency, and insufficient information may threaten patient safety. The aim of this study was to assess the completeness of referrals for lower extremity venous duplex ultrasonography (LEVDUS) and computed tomography pulmonary angiography (CTPA), and to investigate associations between the provided clinical information including risk factors, symptoms and lab results in the referrals and positive findings of deep vein thrombosis (DVT) and pulmonary embolism (PE), respectively. METHODS Referrals for LEVDUS (801) and CTPA (800) performed from 2016 to 2019 were obtained. Three categories of clinical information from the referrals were recorded: symptoms, risk factors and laboratory results, as well as positive imaging findings of venous thromboembolism (VTE). Referral completeness was rated from zero to three according to how many categories of clinical information the referral provided. RESULTS Information from all three clinical information categories was provided in 15% and 25% of referrals for LEVDUS and CTPA, respectively, while 2% and 10% of referrals did not contain any clinical information. Symptoms were provided most often (85% for LEVDUS and 94% for CTPA). Provided information about risk factors was significantly associated with positive findings for LEVDUS, (p = 0.02) and CTPA (p < 0.001). CONCLUSION A great majority of referrals failed to provide one or more categories of clinical information. Risk factors were associated with a positive finding of VTE on LEVDUS and CTPA. IMPLICATIONS FOR PRACTICE Improving clinical information in referrals may improve justification, patient safety and quality of radiology services.
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Affiliation(s)
- S Naimi
- Department of Life Sciences and Health, Oslo Metropolitan University, P.O. Box 4 St. Olavs Plass, NO-0130 Oslo, Norway.
| | - K J Ødegaard
- Department of Radiology, Lovisenberg Diaconal Hospital, Postboks 4970 Nydalen, NO-0440 Oslo, Norway.
| | - K K Jenssen
- Department of Orthopedic Surgery, Lovisenberg Diaconal Hospital, Postboks 4970 Nydalen, NO-0440 Oslo, Norway.
| | - P M Lauritzen
- Department of Life Sciences and Health, Oslo Metropolitan University, P.O. Box 4 St. Olavs Plass, NO-0130 Oslo, Norway; Division of Radiology and Nuclear Medicine, Oslo University Hospital, Postboks 4956 Nydalen, NO-0424 Oslo, Norway.
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Diagnostic test accuracy of imaging modalities for adults with acute pulmonary embolism: A systematic review and meta-analysis. J Med Imaging Radiat Sci 2023; 54:178-194. [PMID: 36456459 DOI: 10.1016/j.jmir.2022.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Revised: 10/26/2022] [Accepted: 11/07/2022] [Indexed: 11/29/2022]
Abstract
OBJECTIVES This systematic review and meta-analysis aimed to evaluate the current literature on diagnostic test accuracy (DTA) of imaging modalities for adults with acute pulmonary embolism (APE). BACKGROUND Medical imaging plays an integral role in evaluating and managing those with APE. Guidance for imaging modality use for APE diagnosis varies due to a lack of clinical standardisation. Despite this, CTPA remains the first-line imaging modality used by clinicians. METHODS A literature search of PubMed, EMBASE, Trove and Mednar databases (2012-2020; English language) was performed. Studies assessing the DTA of imaging modalities for APE diagnosis were included. DTA studies methodological quality was assessed using the Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2 tool). Results of eligible studies were pooled using random or fixed effects modelling the calculate the pooled DTA of explored imaging modalities for APE. The Higgins I2 test were performed to assess between study heterogeneity. RESULTS 10 Studies, involving 998 participants, were enrolled and pooled using the random effects model. Of the explored modalities, magnetic resonance imaging (MRI), specifically pulmonary MRI and magnetic resonance pulmonary angiography (MRPA) exhibited the highest pooled DTA. Sensitivity, specificity, negative likelihood ratio, positive likelihood ratio and diagnostic odds ratio for MRPA were 0.952 (95% CI, 0.881 to 0.987), 0.857 (95% CI, 0.637 to 0.97), 5.631 (95% CI, 2.163 to 14.659), 0.06 (95% CI, 0.007 to 0.537) and 80.310 (95% CI, 15.607 to 413.25) respectively. Based on the QUADAS-2 criteria, most studies presented low to moderate risk of bias and concern regarding applicability. CONCLUSION The explored ultrasound and MRI protocols which exhibit a lower radiation burden when compared to the current gold standard computed tomography pulmonary angiography (CTPA), have acceptable diagnostic accuracy for APE and can be useful in certain situations.
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Mccandlish JA, Feizullayeva C, Spyropoulos A, Cronin PP, Naidich J, Brenner B, Mcginn T, Sanelli PC, Cohen SL. Comparison of guidelines for evaluation of suspected PE in pregnancy: a cost-effectiveness analysis. Chest 2021; 161:1628-1641. [PMID: 34914975 DOI: 10.1016/j.chest.2021.11.036] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 11/11/2021] [Accepted: 11/27/2021] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Pulmonary embolism (PE) remains a leading cause of maternal mortality, yet diagnosis remains challenging. International diagnostic guidelines vary significantly in their recommendations, making it difficult to determine an optimal policy for evaluation. RESEARCH QUESTION Which societal-level diagnostic guideline for evaluation of suspected PE in pregnancy is an optimal policy in terms of its cost-effectiveness? STUDY DESIGN AND METHODS We constructed a complex Markov decision model to evaluate the cost-effectiveness of each identified societal guideline for diagnosis of PE in pregnancy. Our model accounted for risk stratification, empiric treatment, diagnostic testing strategies, as well as short- and long-term effects from PE, treatment with low-molecular weight heparin, and radiation exposure from advanced imaging. We considered clinical and cost outcomes of each guideline from a U.S. health care system perspective with a lifetime horizon. Clinical effectiveness and costs were measured in time-discounted quality-adjusted life years (QALYs) and U.S. dollars respectively. Strategies were compared using the incremental cost-effectiveness ratio (ICER) with a willingness-to-pay threshold of $100,000 per QALY. One-way, multi-way, and probabilistic sensitivity analyses were performed. RESULTS We identified six international societal-level guidelines. Base-case analysis showed the guideline proposed by the American Thoracic Society-Society of Thoracic Radiology (ATS-STR) yielded the highest health benefits (22.90 QALYs) and was cost-effective, with an ICER of $7,808 over the guideline proposed by the Australian Society of Thrombosis and Haemostasis and the Society of Obstetric Medicine of Australia and New Zealand (ASTH-SOMANZ). All remaining guidelines were dominated. The ATS-STR guideline-recommended strategy yielded an expected additional 2.7 QALYs per 100 patients evaluated over the ASTH-SOMANZ. Conclusions were robust to sensitivity analyses, with the ATS-STR guideline optimal in 86% of probabilistic sensitivity analysis scenarios. INTERPRETATION The ATS-STR guideline for diagnosis of suspected PE in pregnancy is cost-effective and generates better expected health outcomes than guidelines proposed by other medical societies.
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Affiliation(s)
- John Austin Mccandlish
- Imaging Clinical Effectiveness and Outcomes Research (ICEOR), Department of Radiology, Northwell Health, Manhasset, New York; Center for Health Innovations and Outcomes Research (CHIOR), Feinstein Institutes for Medical Research and Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York; Georgia Institute of Technology, Atlanta, Georgia
| | - Chinara Feizullayeva
- Imaging Clinical Effectiveness and Outcomes Research (ICEOR), Department of Radiology, Northwell Health, Manhasset, New York; Center for Health Innovations and Outcomes Research (CHIOR), Feinstein Institutes for Medical Research and Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York
| | - Alex Spyropoulos
- The Institute for Health System Science, The Feinstein Institutes for Medical Research and The Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA; Department of Medicine, Anticoagulation and Clinical Thrombosis Services, Northwell Health at Lenox Hill Hospital, New York, NY, USA; Department of Obstetrics and Gynecology, I.M. Sechenov First Moscow State Medical University, Moscow, Russia
| | - Paul P Cronin
- Emory University Hospital Department Of Radiology and Imaging Science, Atlanta, Georgia
| | - Jason Naidich
- Imaging Clinical Effectiveness and Outcomes Research (ICEOR), Department of Radiology, Northwell Health, Manhasset, New York
| | - Benjamin Brenner
- Department of Hematology, Rambam Health Care Campus, Haifa, Israel; The Ruth and Bruce Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel; Department of Obstetrics and Gynaecology, The First I.M. Sechenov Moscow State Medical University (Sechenov University), Moscow, Russia
| | - Thomas Mcginn
- Center for Health Innovations and Outcomes Research (CHIOR), Feinstein Institutes for Medical Research and Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York
| | - Pina C Sanelli
- Imaging Clinical Effectiveness and Outcomes Research (ICEOR), Department of Radiology, Northwell Health, Manhasset, New York; Center for Health Innovations and Outcomes Research (CHIOR), Feinstein Institutes for Medical Research and Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York
| | - Stuart L Cohen
- Imaging Clinical Effectiveness and Outcomes Research (ICEOR), Department of Radiology, Northwell Health, Manhasset, New York; Center for Health Innovations and Outcomes Research (CHIOR), Feinstein Institutes for Medical Research and Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York.
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Ehrman RR, Malik AN, Smith RK, Kalarikkal Z, Huang A, King RM, Green RD, O'Neil BJ, Sherwin RL. Serial use of existing clinical decisions aids can reduce computed tomography pulmonary angiography for pulmonary embolism. Intern Emerg Med 2021; 16:2251-2259. [PMID: 33742340 DOI: 10.1007/s11739-021-02703-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Accepted: 03/08/2021] [Indexed: 12/13/2022]
Abstract
Pulmonary embolism (PE) remains a diagnostic challenge in emergency medicine. Clinical decision aids (CDAs) like the Pulmonary Embolism Rule-Out Criteria (PERC) are sensitive but poorly specific; serial CDA use may improve specificity. The goal of this before-and-after study was to determine if serial use of existing CDAs in a novel diagnostic algorithm safely decreases the use of CT pulmonary angiograms (CTPA). This was a retrospective before-and-after study conducted at an urban ED with 105,000 annual visits. Our algorithm uses PERC, Wells' score, and D-dimer in series, before moving to CTPA. The algorithm was introduced in January, 2017. Use of CDAs and D-dimer in the 24 months pre- and 12 months post-intervention were obtained by chart review. The algorithm's effect on CTPA ordering was assessed by comparing volume 5 years pre- and 3 years post-intervention, adjusted for ED volume. Mean CTPAs per 1000 adult ED visits was 11.1 in the 5 pre-intervention years and 9.9 in the 3 post-intervention years (p < 0.0001). Use of PERC, Wells' score and D-dimer increased from 1.1%, 1.1%, and 28% to 8.8% (p = 0.0002) 8.1% (p = 0.0005), and 35% (p = 0.0066), respectively. Pre-intervention, there were six potentially missed PEs compared to three in the post-intervention period. Introduction of our serial CDA diagnostic algorithm was associated with increased use of CDAs and D-dimer and reduced CTPA rate without an apparent increase in the number of missed PEs. Prospective validation is needed to confirm these results.
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Affiliation(s)
- Robert Russell Ehrman
- Department of Emergency Medicine, Wayne State University School of Medicine; Detroit Medical Center/Sinai-Grace Hospital, 4201 St. Antoine, Suite 6G, Detroit, MI, 48201, USA.
| | - Adrienne Nicole Malik
- Department of Emergency Medicine, Wayne State University School of Medicine; Detroit Medical Center/Sinai-Grace Hospital, 4201 St. Antoine, Suite 6G, Detroit, MI, 48201, USA
| | - Reid Kenneth Smith
- Department of Emergency Medicine, Wayne State University School of Medicine; Detroit Medical Center/Sinai-Grace Hospital, 4201 St. Antoine, Suite 6G, Detroit, MI, 48201, USA
| | - Zeid Kalarikkal
- Department of Emergency Medicine, Wayne State University School of Medicine; Detroit Medical Center/Sinai-Grace Hospital, 4201 St. Antoine, Suite 6G, Detroit, MI, 48201, USA
| | - Andrew Huang
- Department of Emergency Medicine, Wayne State University School of Medicine; Detroit Medical Center/Sinai-Grace Hospital, 4201 St. Antoine, Suite 6G, Detroit, MI, 48201, USA
| | - Ryan Michael King
- Department of Emergency Medicine, Wayne State University School of Medicine; Detroit Medical Center/Sinai-Grace Hospital, 4201 St. Antoine, Suite 6G, Detroit, MI, 48201, USA
| | - Rubin David Green
- Department of Emergency Medicine, Wayne State University School of Medicine; Detroit Medical Center/Sinai-Grace Hospital, 4201 St. Antoine, Suite 6G, Detroit, MI, 48201, USA
| | - Brian James O'Neil
- Department of Emergency Medicine, Wayne State University School of Medicine; Detroit Medical Center/Detroit Receiving Hospital, Detroit, USA
| | - Robert Leigh Sherwin
- Department of Emergency Medicine, Wayne State University School of Medicine; Detroit Medical Center/Sinai-Grace Hospital, 4201 St. Antoine, Suite 6G, Detroit, MI, 48201, USA
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Cost-effectiveness of diagnostic strategies for venous thromboembolism: a systematic review. Blood Adv 2021; 6:544-567. [PMID: 34607343 PMCID: PMC8791567 DOI: 10.1182/bloodadvances.2020003576] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 07/27/2021] [Indexed: 11/30/2022] Open
Abstract
Guideline developers consider cost-effectiveness evidence in decision making to determine value for money. This consideration in the guideline development process can be informed either by formal and dedicated economic evaluations or by systematic reviews of existing studies. To inform the American Society of Hematology guideline on the diagnosis of venous thromboembolism (VTE), we conducted a systematic review focused on the cost-effectiveness of diagnostic strategies for VTE within the guideline scope. We systematically searched Medline (Ovid), Embase (Ovid), National Health Service Economic Evaluation Database, and the Cost-effectiveness Analysis Registry; summarized; and critically appraised the economic evidence on diagnostic strategies for VTE. We identified 49 studies that met our inclusion criteria, with 26 on pulmonary embolism (PE) and 24 on deep vein thrombosis (DVT). For the diagnosis of PE, strategies including d-dimer to exclude PE were cost-effective compared with strategies without d-dimer testing. The cost-effectiveness of computed tomography pulmonary angiogram (CTPA) in relation to ventilation-perfusion (V/Q) scan was inconclusive. CTPA or V/Q scan following ultrasound or d-dimer results could be cost-effective or even cost saving. For DVT, studies supporting strategies with d-dimer and/or ultrasound were cost-effective, supporting the recommendation that for patients at low (unlikely) VTE risk, using d-dimer as the initial test reduces the need for diagnostic imaging. Our systematic review informed the American Society of Hematology guideline recommendations about d-dimer, V/Q scan and CTPA for PE diagnosis, and d-dimer and ultrasound for DVT diagnosis.
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Zalmay P, Zalmay K, Treherne K. The Jury Is Still Out on Routine Use of D-Dimer in Medical Illness. Am J Med 2021; 134:e471. [PMID: 34340759 DOI: 10.1016/j.amjmed.2021.02.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Accepted: 02/15/2021] [Indexed: 11/15/2022]
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Hamilton TD, MacNeill AJ, Lim H, Hunink MGM. Cost-Effectiveness Analysis of Cytoreductive Surgery and HIPEC Compared With Systemic Chemotherapy in Isolated Peritoneal Carcinomatosis From Metastatic Colorectal Cancer. Ann Surg Oncol 2019; 26:1110-1117. [DOI: 10.1245/s10434-018-07111-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Indexed: 12/15/2022]
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9
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Francis S, Limkakeng A, Zheng H, Hollander J, Fermann G, Parry BA, Lovecchio F, Werner N, Schellong S, Kabrhel C. Highly Elevated Quantitative D-Dimer Assay Values Increase the Likelihood of Venous Thromboembolism. TH OPEN 2019; 3:e2-e9. [PMID: 31249975 PMCID: PMC6524895 DOI: 10.1055/s-0038-1677029] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Accepted: 11/29/2018] [Indexed: 01/09/2023] Open
Abstract
Objectives
In patients with suspected venous thromboembolism (VTE), the D-dimer assay is commonly utilized as part of the workup. The assay is primarily used to determine whether to proceed with radiographic imaging. We compared D-dimer levels in patients suspected of having VTE. We hypothesized that higher D-dimer values predict a higher likelihood of subsequent VTE diagnosis.
Methods
We conducted a secondary analysis of a multinational, prospective observational study of low- to intermediate-risk adult patients presenting to the emergency department with suspicion of VTE. Demographic and clinical data were collected in a structured manner. Advanced imaging including ultrasound, computed tomography (CT) pulmonary angiography, and ventilation/perfusion scanning was obtained at the discretion of the treating physicians. Imaging was evaluated by board-certified radiologists in real time. D-dimer values' bins were evaluated using a logistic regression model.
Results
We evaluated 1,752 patients for suspected deep vein thrombosis (DVT), with 191 (10.4%) DVT positive. We evaluated 1,834 patients for suspected pulmonary embolism (PE), with 108 (5.9%) PE positive. Higher D-dimer values in both groups were associated with higher likelihood of subsequent VTE diagnosis, with D-dimer values > 3,999 ng/mL in both groups having the highest incidence of VTE. More than 50% of those patients were VTE positive.
Conclusions
Increasing D-dimer values predict increased likelihood of being found VTE positive in this patient population. Among those in the highest D-dimer category, > 3,999 ng/mL, over half of patients were VTE positive. Further research could determine additional nuance in D-dimer as a tool to work up suspected VTE.
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Affiliation(s)
- Samuel Francis
- Division of Emergency Medicine, Duke University Hospital, Durham, North Carolina, United States
| | - Alexander Limkakeng
- Division of Emergency Medicine, Duke University Hospital, Durham, North Carolina, United States
| | - Hui Zheng
- Department of Biostatistics, Massachusetts General Hospital, Boston, Massachusetts, United States
| | - Judd Hollander
- Department of Emergency Medicine, Jefferson University, Philadelphia, Pennsylvania, United States
| | - Gregory Fermann
- Department of Emergency Medicine, University of Cincinnati, Cincinnati, Ohio, United States
| | - Blair Alden Parry
- Department of Emergency Medicine, Center for Vascular Emergencies, Massachusetts General Hospital, Boston, Massachusetts, United States
| | - Frank Lovecchio
- Department of Emergency Medicine, Maricopa Hospital, Phoenix, Arizona, United States
| | - Nikos Werner
- International Center for Cardiovascular Interventions, Heart Center Bonn, Medizinischen Klinik und Poliklinik II, Bonn, Germany
| | | | - Christopher Kabrhel
- Department of Emergency Medicine, Center for Vascular Emergencies, Massachusetts General Hospital, Boston, Massachusetts, United States
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Ademi Z, Sutherland CS, Van Stiphout J, Michaud J, Tanackovic G, Schwenkglenks M. A systematic review of cost-effectiveness analysis of screening interventions for assessing the risk of venous thromboembolism in women considering combined oral contraceptives. J Thromb Thrombolysis 2018; 44:494-506. [PMID: 28918448 DOI: 10.1007/s11239-017-1554-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Use of combined oral contraceptives (COCs) by women increases the risk of venous thromboembolism (VTE), which can have a major impact on an individuals' quality of life. VTE is also associated with an increase in healthcare costs. Our aim was to systematically review cost-effectiveness analyses (CEAs) considering any screening for risk of VTE in women using COCs. The quality of reporting in each study was assessed, a summary of results was prepared, and the key drivers of cost effectiveness in each of the eligible CEAs were identified. A search strategy using MeSH terms was performed in MEDLINE, Embase, the Centre for Review and Dissemination (CRD) database including the Economic Evaluation Database from the UK National Health Service, and Cochrane reviews. Two reviewers independently screened and determined the final articles, and a third reviewer resolved any discrepancies. Consolidated Health Economic Evaluation Reporting Standards was used to assess the quality of reporting in terms of perspective, effectiveness measures, model structure, cost, time-horizon and discounting. Four publications (three from Europe, one from the United States) were eligible for inclusion in the review. According to current criteria, relevant elements were sometimes not captured and the sources of epidemiological and effectiveness data used in the CEAs were of limited quality. The studies varied in terms of type of costs assessed, country settings, model assumptions and uncertainty around input parameters. Key drivers of CEAs were sensitivity and specificity of the test, incidence rate of VTE, relative risk of prophylaxis, and costs of the test. The reviewed studies were too dissimilar to draw a firm conclusion on cost-effectiveness analysis about universal and selective screening in high-risk groups. The new emerging diagnostic tools for identifying women at risk of developing VTE, that are more predictive and less costly, highlight the need for more studies that apply the latest evidence and utilize robust methods for cost-effectiveness analysis. This information is required to improve decision making for this pertinent issue within personalized medicine.
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Affiliation(s)
- Zanfina Ademi
- Institute of Pharmaceutical Medicine (ECPM), University of Basel, Basel, Switzerland. .,Monash Centre of Cardiovascular Research and Education in Therapeutics, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia.
| | - C Simone Sutherland
- Institute of Pharmaceutical Medicine (ECPM), University of Basel, Basel, Switzerland
| | - Joris Van Stiphout
- Institute of Pharmaceutical Medicine (ECPM), University of Basel, Basel, Switzerland
| | - Jöelle Michaud
- Gene Predictis SA, EPFL Innovation Park, Lausanne, Switzerland
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van der Pol LM, Dronkers CEA, van der Hulle T, den Exter PL, Tromeur C, Heringhaus C, Mairuhu ATA, Huisman MV, van den Hout WB, Klok FA. The YEARS algorithm for suspected pulmonary embolism: shorter visit time and reduced costs at the emergency department. J Thromb Haemost 2018; 16:725-733. [PMID: 29431911 DOI: 10.1111/jth.13972] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Indexed: 08/31/2023]
Abstract
Essentials The YEARS algorithm was designed to simplify the diagnostic workup of suspected pulmonary embolism. We compared emergency ward turnaround time of YEARS and the conventional algorithm. YEARS was associated with a significantly shorter emergency department visit time of ˜60 minutes. Treatment of pulmonary embolism was initiated 53 minutes earlier with the YEARS algorithm SUMMARY: Background Recently, the safety of the YEARS algorithm, designed to simplify the diagnostic work-up of pulmonary embolism (PE), was demonstrated. We hypothesize that by design, YEARS would be associated with a shorter diagnostic emergency department (ED) visit time due to simultaneous assessment of pre-test probability and D-dimer level and reduction in number of CT scans. Aim To investigate whether implementation of the YEARS diagnostic algorithm is associated with a shorter ED visit time compared with the conventional algorithm and to evaluate the associated cost savings. Methods We selected consecutive outpatients with suspected PE from our hospital included in the YEARS study and ADJUST-PE study. Different time-points of the diagnostic process were extracted from the to-the-minute accurate electronic patients' chart system of the ED. Further, the costs of the ED visits were estimated for both algorithms. Results All predefined diagnostic turnaround times were significantly shorter after implementation of YEARS: patients were discharged earlier from the ED; 54 min (95% CI, 37-70) for patients managed without computed tomography pulmonary angiography (CTPA) and 60 min (95% CI, 44-76) for the complete study population. Importantly, patients diagnosed with PE by CTPA received the first dose of anticoagulants 53 min (95% CI, 22-82) faster than those managed according to the conventional algorithm. Total costs were reduced by on average €123 per visit. Conclusion YEARS was shown to be associated with a shorter ED visit time compared with the conventional diagnostic algorithm, leading to faster start of treatment in the case of confirmed PE and savings on ED resources.
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Affiliation(s)
- L M van der Pol
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
- Department of Internal Medicine, Haga Teaching Hospital, The Hague, the Netherlands
| | - C E A Dronkers
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - T van der Hulle
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - P L den Exter
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - C Tromeur
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - C Heringhaus
- Department of Emergency Medicine, Leiden University Medical Center, Leiden, the Netherlands
| | - A T A Mairuhu
- Department of Internal Medicine, Haga Teaching Hospital, The Hague, the Netherlands
| | - M V Huisman
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - W B van den Hout
- Department of Medical Decision Making and Quality of CareLeiden University Medical Center, Leiden, the Netherlands
| | - F A Klok
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
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12
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Diagnosis and Exclusion of Pulmonary Embolism. Thromb Res 2018; 163:207-220. [DOI: 10.1016/j.thromres.2017.06.002] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2017] [Revised: 05/30/2017] [Accepted: 06/05/2017] [Indexed: 12/21/2022]
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Deblois S, Chartrand-Lefebvre C, Toporowicz K, Chen Z, Lepanto L. Interventions to Reduce the Overuse of Imaging for Pulmonary Embolism: A Systematic Review. J Hosp Med 2018; 13:52-61. [PMID: 29309438 DOI: 10.12788/jhm.2902] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Imaging use in the diagnostic workup of pulmonary embolism (PE) has increased markedly in the last 2 decades. Low PE prevalence and diagnostic yields suggest a significant problem of overuse. PURPOSE The purpose of this systematic review is to summarize the evidence associated with the interventions aimed at reducing the overuse of imaging in the diagnostic workup of PE in the emergency department and hospital wards. DATA SOURCES PubMed, MEDLINE, Embase, and EBM Reviews from 1998 to March 28, 2017. STUDY SELECTION Experimental and observational studies were included. The types of interventions, their efficacy and safety, the impact on healthcare costs, the facilitators, and barriers to their implementation were assessed. DATA SYNTHESIS Seventeen studies were included assessing clinical decision support (CDS), educational interventions, performance and feedback reports (PFRs), and institutional policy. CDS impact was most comprehensively documented. It was associated with a reduction in imaging use, ranging from 8.3% to 25.4%, and an increase in diagnostic yield, ranging from 3.4% to 4.4%. The combined implementation of a CDS and PFR resulted in a modest but significant increase in the adherence to guidelines. Few studies appraised the safety of interventions. There was a lack of evidence concerning economic aspects, facilitators, and barriers. CONCLUSIONS A combined implementation of an electronic CDS and PFRs is more effective than purely educational or policy interventions, although evidence is limited. Future studies of high-methodological quality would strengthen the evidence concerning their efficacy, safety, facilitators, and barriers.
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Affiliation(s)
- Simon Deblois
- Health Technology Assessment Unit, Centre Hospitalier de l'Université de Montréal (CHUM), Montréal, Québec, Canada.
| | - Carl Chartrand-Lefebvre
- Radiology Department, Centre Hospitalier de l'Université de Montréal (CHUM), Montréal, Québec, Canada
- Centre de Recherche du CHUM, Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada
| | - Kevin Toporowicz
- Radiology Department, Centre Hospitalier de l'Université de Montréal (CHUM), Montréal, Québec, Canada
| | - Zhongyi Chen
- Radiology Department, Centre Hospitalier de l'Université de Montréal (CHUM), Montréal, Québec, Canada
| | - Luigi Lepanto
- Health Technology Assessment Unit, Centre Hospitalier de l'Université de Montréal (CHUM), Montréal, Québec, Canada
- Centre de Recherche du CHUM, Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada
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Nonoperative management of adhesive small bowel obstruction: what is the break point? Am J Surg 2016; 212:1214-1221. [DOI: 10.1016/j.amjsurg.2016.09.037] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2016] [Revised: 09/10/2016] [Accepted: 09/14/2016] [Indexed: 11/22/2022]
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Corrigan D, Prucnal C, Kabrhel C. Pulmonary embolism: the diagnosis, risk-stratification, treatment and disposition of emergency department patients. Clin Exp Emerg Med 2016; 3:117-125. [PMID: 27752629 PMCID: PMC5065342 DOI: 10.15441/ceem.16.146] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2016] [Revised: 05/25/2016] [Accepted: 05/25/2016] [Indexed: 12/15/2022] Open
Abstract
The diagnosis or exclusion of pulmonary embolism (PE) remains challenging for emergency physicians. Symptoms can be vague or non-existent, and the clinical presentation shares features with many other common diagnoses. Diagnostic testing is complicated, as biomarkers, like the D-dimer, are frequently false positive, and imaging, like computed tomography pulmonary angiography, carries risks of radiation and contrast dye exposure. It is therefore incumbent on emergency physicians to be both vigilant and thoughtful about this diagnosis. In recent years, several advances in treatment have also emerged. Novel, direct-acting oral anticoagulants make the outpatient treatment of low risk PE easier than before. However, the spectrum of PE severity varies widely, so emergency physicians must be able to risk-stratify patients to ensure the appropriate disposition. Finally, PE response teams have been developed to facilitate rapid access to advanced therapies (e.g., catheter directed thrombolysis) for patients with high-risk PE. This review will discuss the clinical challenges of PE diagnosis, risk stratification and treatment that emergency physicians face every day.
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Affiliation(s)
- Daniel Corrigan
- Center for Vascular Emergencies, Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Christiana Prucnal
- Center for Vascular Emergencies, Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Christopher Kabrhel
- Center for Vascular Emergencies, Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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Raja AS, Greenberg JO, Qaseem A, Denberg TD, Fitterman N, Schuur JD. Evaluation of Patients With Suspected Acute Pulmonary Embolism: Best Practice Advice From the Clinical Guidelines Committee of the American College of Physicians. Ann Intern Med 2015; 163:701-11. [PMID: 26414967 DOI: 10.7326/m14-1772] [Citation(s) in RCA: 197] [Impact Index Per Article: 21.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
DESCRIPTION Pulmonary embolism (PE) can be a severe disease and is difficult to diagnose, given its nonspecific signs and symptoms. Because of this, testing patients with suspected acute PE has increased dramatically. However, the overuse of some tests, particularly computed tomography (CT) and plasma d-dimer measurement, may not improve care while potentially leading to patient harm and unnecessary expense. METHODS The literature search encompassed studies indexed by MEDLINE (1966-2014; English-language only) and included all clinical trials and meta-analyses on diagnostic strategies, decision rules, laboratory tests, and imaging studies for the diagnosis of PE. This document is not based on a formal systematic review, but instead seeks to provide practical advice based on the best available evidence and recent guidelines. The target audience for this paper is all clinicians; the target patient population is all adults, both inpatient and outpatient, suspected of having acute PE. BEST PRACTICE ADVICE 1 Clinicians should use validated clinical prediction rules to estimate pretest probability in patients in whom acute PE is being considered. BEST PRACTICE ADVICE 2 Clinicians should not obtain d-dimer measurements or imaging studies in patients with a low pretest probability of PE and who meet all Pulmonary Embolism Rule-Out Criteria. BEST PRACTICE ADVICE 3 Clinicians should obtain a high-sensitivity d-dimer measurement as the initial diagnostic test in patients who have an intermediate pretest probability of PE or in patients with low pretest probability of PE who do not meet all Pulmonary Embolism Rule-Out Criteria. Clinicians should not use imaging studies as the initial test in patients who have a low or intermediate pretest probability of PE. BEST PRACTICE ADVICE 4 Clinicians should use age-adjusted d-dimer thresholds (age × 10 ng/mL rather than a generic 500 ng/mL) in patients older than 50 years to determine whether imaging is warranted. BEST PRACTICE ADVICE 5 Clinicians should not obtain any imaging studies in patients with a d-dimer level below the age-adjusted cutoff. BEST PRACTICE ADVICE 6 Clinicians should obtain imaging with CT pulmonary angiography (CTPA) in patients with high pretest probability of PE. Clinicians should reserve ventilation-perfusion scans for patients who have a contraindication to CTPA or if CTPA is not available. Clinicians should not obtain a d-dimer measurement in patients with a high pretest probability of PE.
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Affiliation(s)
- Ali S. Raja
- From Massachusetts General Hospital and Brigham and Women's Hospital, Boston, Massachusetts; American College of Physicians, Philadelphia, Pennsylvania; Hofstra North Shore Long Island Jewish School of Medicine, Huntington, New York; and Carilion Clinic, Roanoke, Virginia
| | - Jeffrey O. Greenberg
- From Massachusetts General Hospital and Brigham and Women's Hospital, Boston, Massachusetts; American College of Physicians, Philadelphia, Pennsylvania; Hofstra North Shore Long Island Jewish School of Medicine, Huntington, New York; and Carilion Clinic, Roanoke, Virginia
| | - Amir Qaseem
- From Massachusetts General Hospital and Brigham and Women's Hospital, Boston, Massachusetts; American College of Physicians, Philadelphia, Pennsylvania; Hofstra North Shore Long Island Jewish School of Medicine, Huntington, New York; and Carilion Clinic, Roanoke, Virginia
| | - Thomas D. Denberg
- From Massachusetts General Hospital and Brigham and Women's Hospital, Boston, Massachusetts; American College of Physicians, Philadelphia, Pennsylvania; Hofstra North Shore Long Island Jewish School of Medicine, Huntington, New York; and Carilion Clinic, Roanoke, Virginia
| | - Nick Fitterman
- From Massachusetts General Hospital and Brigham and Women's Hospital, Boston, Massachusetts; American College of Physicians, Philadelphia, Pennsylvania; Hofstra North Shore Long Island Jewish School of Medicine, Huntington, New York; and Carilion Clinic, Roanoke, Virginia
| | - Jeremiah D. Schuur
- From Massachusetts General Hospital and Brigham and Women's Hospital, Boston, Massachusetts; American College of Physicians, Philadelphia, Pennsylvania; Hofstra North Shore Long Island Jewish School of Medicine, Huntington, New York; and Carilion Clinic, Roanoke, Virginia
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17
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Emergency Evaluation for Pulmonary Embolism, Part 2: Diagnostic Approach. J Emerg Med 2015; 49:104-17. [DOI: 10.1016/j.jemermed.2014.12.041] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2014] [Revised: 12/17/2014] [Accepted: 12/21/2014] [Indexed: 12/14/2022]
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Hahne K, Lebiedz P, Breuckmann F. Impact of d-Dimers on the Differential Diagnosis of Acute Chest Pain: Current Aspects Besides the Widely Known. CLINICAL MEDICINE INSIGHTS-CARDIOLOGY 2014; 8:1-4. [PMID: 25392700 PMCID: PMC4216819 DOI: 10.4137/cmc.s15948] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2014] [Accepted: 08/09/2014] [Indexed: 02/03/2023]
Abstract
d-dimers are cleavage products of fibrin that occur during plasmin-mediated fibrinolysis of blood clots. In the emergency department, d-dimer measurement represents a valuable and cost-effective tool in the differential diagnosis of acute chest pain including the main life-threatening entities: acute coronary syndrome, pulmonary embolism, and acute aortic syndrome. Whereas the diagnostic and prognostic values of d-dimer testing in acute coronary syndrome is of less priority, increases of d-dimers are frequently found in venous thromboembolism and acute aortic syndromes, especially acute aortic dissection. As to the high negative predictive value of d-dimer in those disorders, patients with low to intermediate pretest probability may profit in terms of less necessity of further non-invasive or even invasive imaging, simultaneously reducing potential complications and healthcare-related costs. However, because of the low specificity of the different d-dimer tests in contrast to its frequent usage, adequate interpretation is required. Age-related adjustment of d-dimer levels may be used to increase its diagnostic power.
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Affiliation(s)
- Kathrin Hahne
- Department of Cardiovascular Medicine, University Hospital Muenster, Muenster, Germany
| | - Pia Lebiedz
- Department of Cardiovascular Medicine, University Hospital Muenster, Muenster, Germany
| | - Frank Breuckmann
- Department of Cardiology, Arnsberg Medical Center, Arnsberg, Germany
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Adams D, Welch JL, Kline JA. Clinical Utility of an Age-Adjusted D-dimer in the Diagnosis of Venous Thromboembolism. Ann Emerg Med 2014; 64:232-4. [DOI: 10.1016/j.annemergmed.2013.12.018] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2013] [Revised: 12/10/2013] [Accepted: 12/10/2013] [Indexed: 12/31/2022]
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Diagnostic Strategies Incorporating Computed Tomography Angiography for Pulmonary Embolism. J Thorac Imaging 2014; 29:209-16. [DOI: 10.1097/rti.0b013e3182999e41] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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22
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Chen C, Li G, Liu YD, Gu YJ. A New D-dimer Cutoff Value to Improve the Exclusion of Deep Vein Thrombosis in Cancer Patients. Asian Pac J Cancer Prev 2014; 15:1655-8. [DOI: 10.7314/apjcp.2014.15.4.1655] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Perveen S, Unwin D, Shetty AL, Byth K. Response to the comments on 'point of care D-dimer testing in the emergency department--a bioequivalence study' and erratum to the results. Ann Lab Med 2014; 34:66-7. [PMID: 24422200 PMCID: PMC3885777 DOI: 10.3343/alm.2014.34.1.66] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2013] [Revised: 07/26/2013] [Accepted: 08/20/2013] [Indexed: 11/25/2022] Open
Affiliation(s)
| | - Danielle Unwin
- Emergency Department, Westmead Hospital, Sydney, Australia
| | - Amith L Shetty
- Emergency Department, Westmead Hospital, Sydney, Australia
| | - Karen Byth
- Millennium Research Institute, Sydney, Australia
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Compagni A, Melegaro A, Tarricone R. Genetic screening for the predisposition to venous thromboembolism: a cost-utility analysis of clinical practice in the Italian health care system. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2013; 16:909-921. [PMID: 24041341 DOI: 10.1016/j.jval.2013.05.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/31/2012] [Revised: 04/22/2013] [Accepted: 05/04/2013] [Indexed: 06/02/2023]
Abstract
OBJECTIVES In the Italian health care system, genetic tests for factor V Leiden and factor II are routinely prescribed to assess the predisposition to venous thromboembolism (VTE) of women who request oral contraception. With specific reference to two subpopulations of women already at risk (i.e., familial history or previous event of VTE), the study aimed to assess whether current screening practices in Italy are cost-effective. METHODS Two decisional models accrued costs and quality-adjusted life-years (QALY) annually from the perspective of the National Health Service. The two models were derived from a decision analysis exercise concerning testing practices and consequent prescribing behavior for oral contraception conducted with 250 Italian gynecologists. Health care costs were compiled on the basis of 10-year hospital discharge records and the activities of a thrombosis center. Whenever possible, input data were based on the Italian context; otherwise, the data were taken from the international literature. RESULTS Current testing practices on women with a familial history of VTE generate an incremental cost-effectiveness ratio of €72,412/QALY, which is well above the acceptable threshold of cost-effectiveness of €40,000 to €50,000/QALY. In the case of women with a previous event of VTE, the most frequently used testing strategy is cost-ineffective and leads to an overall loss of QALY. CONCLUSIONS This study represents the first attempt to conduct a cost-utility analysis of genetic screening practices for the predisposition to VTE in the Italian setting. The results indicate that there is an urgent need to better monitor the indications for which tests for factor V Leiden and factor II are prescribed.
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Affiliation(s)
- Amelia Compagni
- Department of Policy Analysis and Public Management; Centre for Research in Health and Social Care Management (CeRGAS).
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25
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Pines JM, Lessler AL, Ward MJ, Mark Courtney D. The mortality benefit threshold for patients with suspected pulmonary embolism. Acad Emerg Med 2012; 19:E1109-13. [PMID: 22978741 DOI: 10.1111/j.1553-2712.2012.01432.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES The mortality benefit for pulmonary embolism (PE) is the difference in mortality between treated and untreated patients. The mortality benefit threshold is the mortality benefit above which testing for a condition should be initiated and below which it should not. To illustrate this concept, the authors developed a decision model to estimate the mortality benefit threshold at several pretest probabilities for low-risk emergency department (ED) patients with possible PE and compare those thresholds with contemporary management of PE in the United States and what is known and not known about treatment benefits with anticoagulation. METHODS The authors built a decision model of a 25-year-old female with suspected PE. Model inputs were obtained from the literature or clinical judgment when data were unavailable. One-way sensitivity analysis was used to derive the mortality benefit threshold at several fixed pretest probabilities, and two-way sensitivity analysis was used to determine drivers of the mortality benefit threshold. RESULTS At a 15% pretest probability, the mortality benefit threshold was 3.7%; at 10% it was 5.2%; at 5% it was 9.8%; at 2% it was 23.5%; at 1% it was 46.3%; and at 0.5% it was 92.1%. In two-way sensitivity analyses, D-dimer specificity, CT angiography (CTA)/CT venography (CTV) sensitivity, annual cancer risk, probability of death from renal failure, and probability of major bleeding were major model drivers. CONCLUSIONS The mortality benefit threshold for initiating PE testing is very high at low pretest probabilities of PE, which should be considered by clinicians in their diagnostic approach to PE in the ED. The mortality benefit threshold is a novel way of exploring the benefits and risks of ED-based testing, particularly in situations like PE where testing (i.e., CT use) carries real risks and the benefits of treatment are uncertain.
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Affiliation(s)
- Jesse M Pines
- Departments of Emergency Medicine and Health Policy, George Washington University, Washington, DC, USA.
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Lacson R, Sugarbaker N, Prevedello LM, Ivan I, Mar W, Andriole KP, Khorasani R. Retrieval of radiology reports citing critical findings with disease-specific customization. Open Med Inform J 2012; 6:28-35. [PMID: 22934127 PMCID: PMC3428631 DOI: 10.2174/1874431101206010028] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2012] [Revised: 06/29/2012] [Accepted: 07/14/2012] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Communication of critical results from diagnostic procedures between caregivers is a Joint Commission national patient safety goal. Evaluating critical result communication often requires manual analysis of voluminous data, especially when reviewing unstructured textual results of radiologic findings. Information retrieval (IR) tools can facilitate this process by enabling automated retrieval of radiology reports that cite critical imaging findings. However, IR tools that have been developed for one disease or imaging modality often need substantial reconfiguration before they can be utilized for another disease entity. PURPOSE THIS PAPER: 1) describes the process of customizing two Natural Language Processing (NLP) and Information Retrieval/Extraction applications - an open-source toolkit, A Nearly New Information Extraction system (ANNIE); and an application developed in-house, Information for Searching Content with an Ontology-Utilizing Toolkit (iSCOUT) - to illustrate the varying levels of customization required for different disease entities and; 2) evaluates each application's performance in identifying and retrieving radiology reports citing critical imaging findings for three distinct diseases, pulmonary nodule, pneumothorax, and pulmonary embolus. RESULTS Both applications can be utilized for retrieval. iSCOUT and ANNIE had precision values between 0.90-0.98 and recall values between 0.79 and 0.94. ANNIE had consistently higher precision but required more customization. CONCLUSION Understanding the customizations involved in utilizing NLP applications for various diseases will enable users to select the most suitable tool for specific tasks.
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Affiliation(s)
- Ronilda Lacson
- Brigham and Women's Hospital/Harvard Medical School, 20 Kent St., 2nd Floor, Brookline MA 02445, USA
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Shifting up cutoff value of d-dimer in the evaluation of pulmonary embolism: a viable option? Possible risks and benefits. Emerg Med Int 2012; 2012:517375. [PMID: 22888438 PMCID: PMC3409522 DOI: 10.1155/2012/517375] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2012] [Revised: 05/21/2012] [Accepted: 06/04/2012] [Indexed: 11/17/2022] Open
Abstract
Objectives. To evaluate the viability of the possibility to use a higher D-dimer value than the one used today in the clinical algorithms evaluating patients suspected to have pulmonary embolism. Methods. A retrospective analysis of 300 serial patients for whom D-dimer values were taken during a 10 month period in the emergency room of a tertiary medical center. Results. Our analysis showed that it may be safe and cost effective to use a D-dimer value of 900 ng/ml rather than the value of 500 ng/ml accepted today, with sensitivity of 94.4%. In younger patients [under 40 years] the sensitivity reached was even higher-100%. Conclusions. Raising cutoff values of D-dimer in screening for pulmonary embolism seems a viable option. There may be a place for "tailoring" cutoff values according individual patient characteristics, such as according age groups. More studies of the subject are warranted.
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Stephen JH, Halpern CH, Barrios CJ, Balmuri U, Pisapia JM, Wolf JA, Kampman KM, Baltuch GH, Caplan AL, Stein SC. Deep brain stimulation compared with methadone maintenance for the treatment of heroin dependence: a threshold and cost-effectiveness analysis. Addiction 2012; 107:624-34. [PMID: 21919988 DOI: 10.1111/j.1360-0443.2011.03656.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
AIMS To determine the success threshold at which a theoretical course of deep brain stimulation (DBS) would provide the same quality of life (QoL) and cost-effectiveness for heroin dependence as methadone maintenance treatment (MMT). DESIGN We constructed a decision analysis model to calculate QoL after 6 months of MMT and compared it to a theoretical course of DBS. We also performed a cost-effectiveness analysis using societal costs of heroin dependence, MMT and DBS. SETTING Systematic literature review and meta-analysis. PARTICIPANTS Patients (n = 1191) from 15 trials administering 6 months of MMT and patients (n = 2937) from 45 trials of DBS for movement disorders. MEASUREMENTS Data on QoL before and after MMT, retention in MMT at 6 months, as well as complications of DBS and their impact on QoL in movement disorders. FINDINGS We found a QoL of 0.633 (perfect health = 1) in heroin addicts initiating MMT. Sixty-six per cent of patients completed MMT, but only 47% of them had opiate-free urine samples, resulting in an average QoL of 0.7148 (0.3574 quality-adjusted life years (QALYs) over 6 months). A trial of DBS is less expensive ($81,000) than untreated (or relapsed) heroin dependence ($100,000), but more expensive than MMT ($58,000). A theoretical course of DBS would need a success rate of 36.5% to match MMT, but a success rate of 49% to be cost-effective. CONCLUSIONS The success rate, defined as the percentage of patients remaining heroin-free after 6 months of treatment, at which deep brain stimulation would be similarly cost-effective in treating opiate addiction to methadone maintenance treatment, is estimated at 49%.
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Affiliation(s)
- James H Stephen
- Department of Neurosurgery, Centers for Functional and Restorative Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, PA 19104, USA
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Fesmire FM, Brown MD, Espinosa JA, Shih RD, Silvers SM, Wolf SJ, Decker WW. Critical issues in the evaluation and management of adult patients presenting to the emergency department with suspected pulmonary embolism. Ann Emerg Med 2011; 57:628-652.e75. [PMID: 21621092 DOI: 10.1016/j.annemergmed.2011.01.020] [Citation(s) in RCA: 84] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
This clinical policy from the American College of Emergency Physicians is the revision of a 2003 clinical policy on the evaluation and management of adult patients presenting with suspected pulmonary embolism (PE).(1) A writing subcommittee reviewed the literature to derive evidence-based recommendations to help clinicians answer the following critical questions: (1) Do objective criteria provide improved risk stratification over gestalt clinical assessment in the evaluation of patients with possible PE? (2) What is the utility of the Pulmonary Embolism Rule-out Criteria (PERC) in the evaluation of patients with suspected PE? (3)What is the role of quantitative D-dimer testing in the exclusion of PE? (4) What is the role of computed tomography pulmonary angiogram of the chest as the sole diagnostic test in the exclusion of PE? (5) What is the role of venous imaging in the evaluation of patients with suspected PE? (6) What are the indications for thrombolytic therapy in patients with PE? Evidence was graded and recommendations were given based on the strength of the available data in the medical literature.
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Schriger DL. Dynamic research, static literature. Ann Emerg Med 2010; 56:339-40. [PMID: 20868905 DOI: 10.1016/j.annemergmed.2010.05.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2010] [Revised: 05/04/2010] [Accepted: 05/05/2010] [Indexed: 11/26/2022]
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Kline JA. A Primer on the Complicated Subject of Cost-Effectiveness Analyses for Pulmonary Embolism. Ann Emerg Med 2010; 56:334-8. [DOI: 10.1016/j.annemergmed.2010.04.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2010] [Revised: 04/19/2010] [Accepted: 04/21/2010] [Indexed: 10/19/2022]
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