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Ghobadi A, Lin B, Musigdilok VV, Park SJ, Palmer‐Toy DE, Gould MK, Vinson DR, Hutchison DM, Sharp AL. Effect of Using an Age-adjusted D-dimer to Assess for Pulmonary Embolism in Community Emergency Departments. Acad Emerg Med 2021; 28:60-69. [PMID: 33206443 DOI: 10.1111/acem.14175] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 10/20/2020] [Accepted: 11/14/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND The objective of this study was to evaluate the effect of changing the laboratory-reported D-dimer reference intervals to age-adjusted reference intervals on the use of advanced chest imaging and 30-day adverse events among emergency department (ED) encounters. METHODS A retrospective interrupted time-series analysis of ED encounters for patients > 50 years evaluated for suspected pulmonary embolism (PE) from April 2014 to April 2016. The primary outcome was use of advanced diagnostic imaging, and the secondary outcome was 30-day mortality or PE diagnosis. Secondary analyses also quantified delayed PE diagnoses pre- and postintervention. A generalized estimating equation segmented logistic regression model, adjusting for patient and facility characteristics, was used to determine changes in odds of diagnostic imaging and 30-day mortality or PE diagnoses. RESULTS A total of 10,534 (5,153 pre- and 5,381 postimplementation) ED encounters were included. Advanced imaging was obtained in 35.9% of pre- versus 33% of postimplementation encounters. Age-adjusted D-dimer (AADD) showed a small and nonsignificant decrease in month-to-month trends of advanced chest imaging postimplementation (odds ratio [OR] = 0.98, 95% confidence interval [CI] = 0.96 to 1.00). Use of advanced imaging in patients with D-dimer values lower than 500 ng/mL fibrinogen-equivalent units (FEU) was similar in the preintervention (5.8%) and postintervention (6.8%) periods. However, imaging was obtained in 30% of patients postintervention with a D-dimer result less than AADD reference interval , but more than the historical 500 ng/mL FEU reference interval. Implementing an AADD threshold demonstrated no change in the rate of 30-day adverse events (missed PE or mortality). CONCLUSION Changing the laboratory-reported D-dimer reference intervals for evaluation of PE was not associated with reduction in advanced chest imaging and did not increase 30-day adverse events. However, there was substantial noncompliance with the age-adjusted reference intervals in the postintervention period likely blunting the impact of this intervention.
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Affiliation(s)
- Ali Ghobadi
- From the Department of Clinical Science Kaiser Permanente Bernard J. Tyson School of Medicine PasadenaCAUSA
- the Anaheim Medical Center Kaiser Permanente Southern California Anaheim CAUSA
| | - Bryan Lin
- the Department of Research and Evaluation Kaiser Permanente PasadenaCAUSA
| | | | - Stacy J. Park
- the Department of Research and Evaluation Kaiser Permanente PasadenaCAUSA
| | - Darryl E. Palmer‐Toy
- the Southern California Permanente Medical Group Regional Reference Laboratories North Hollywood and Chino Hills CAUSA
| | - Michael K. Gould
- the Department of Research and Evaluation Kaiser Permanente PasadenaCAUSA
- the Department of Health Systems Science Kaiser Permanente Bernard J. Tyson School of Medicine Pasadena CAUSA
| | - David R. Vinson
- the Department of Research, and The Permanente Medical Group Kaiser Permanente Northern California Oakland CAUSA
- the Kaiser Permanente Roseville Medical Center Roseville CAUSA
| | | | - Adam L. Sharp
- the Department of Research and Evaluation Kaiser Permanente PasadenaCAUSA
- the Department of Health Systems Science Kaiser Permanente Bernard J. Tyson School of Medicine Pasadena CAUSA
- and the Los Angeles Medical Center Kaiser Permanente Southern California Los Angeles CA USA
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Germini F, Zarabi S, Eventov M, Turcotte M, Li M, de Wit K. Pulmonary embolism prevalence among emergency department cohorts: A systematic review and meta-analysis by country of study. J Thromb Haemost 2021; 19:173-185. [PMID: 33048461 DOI: 10.1111/jth.15124] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2020] [Revised: 09/08/2020] [Accepted: 09/28/2020] [Indexed: 12/30/2022]
Abstract
Essentials The threshold to test for pulmonary embolism (PE) might be lower in North America than Europe. We compared the PE prevalence and positive yield of imaging in Europe and North America. More patients tested in Europe are diagnosed with PE, and imaging is more often positive. Our systematic review supports the hypothesis of overtesting for PE in North America. ABSTRACT: Background There is an impression that North American emergency department (ED) patients tested for pulmonary embolism (PE) differ from European ones. Objectives We compared the PE prevalence, frequency of use, and positive yield of imaging among ED patients tested for PE in Europe and North America. Methods We searched for studies reporting consecutive ED patients tested for PE. Two authors screened full texts, performed risk of bias assessment, and data extraction. We conducted a meta-analysis of proportions for each outcome and a multiple meta-regression. Results From 3109 publications, 44 were included in the systematic review. The prevalence of PE in Europe was 23% (95% confidence interval [CI], 21-26) and in North America 8% (95% CI, 6-9). The adjusted mean difference (aMD) in the prevalence of PE in the European compared with North American studies, was 15% (95% CI, 10-20). Computed tomography pulmonary angiography (CTPA) was used in 60% (95% CI, 52%-68) of European and 38% (95% CI, 24-51) of North American patients tested for PE (aMD, 23% [95% CI, 7-39]). The CTPA diagnostic yield was 29% (95% CI, 26-32) in Europe and 13% (95% CI, 9-17) in North America (aMD, 15% [95% CI, 8-21]). Conclusion Compared with North America, European ED studies have a higher prevalence of PE and diagnostic yield from CTPA, despite a higher frequency of CTPA use among patients tested for PE. This supports the hypothesis that those tested for PE in North American EDs have a lower risk of PE compared with Europe.
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Affiliation(s)
- Federico Germini
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
- Division of Emergency Medicine, Department of Medicine, McMaster University, Hamilton, Canada
- Department of Health Sciences, Università degli Studi di Milano, Milano, Italy
| | - Sahar Zarabi
- Division of Emergency Medicine, Department of Medicine, McMaster University, Hamilton, Canada
| | - Michelle Eventov
- Division of Emergency Medicine, Department of Medicine, McMaster University, Hamilton, Canada
| | - Michelle Turcotte
- Division of Emergency Medicine, Department of Medicine, McMaster University, Hamilton, Canada
| | - Meirui Li
- Division of Emergency Medicine, Department of Medicine, McMaster University, Hamilton, Canada
| | - Kerstin de Wit
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
- Division of Emergency Medicine, Department of Medicine, McMaster University, Hamilton, Canada
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Lim MS, Bennett A, Chunilal S. Age-adjusted cut-off using the IL D-dimer HS assay to exclude pulmonary embolism in patients presenting to emergency. Intern Med J 2018; 48:1096-1101. [PMID: 29869406 DOI: 10.1111/imj.13992] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Revised: 05/04/2018] [Accepted: 05/27/2018] [Indexed: 12/16/2022]
Abstract
BACKGROUND/AIM The ADJUST-PE study showed that an age-adjusted D-dimer (AADD) (age years × 10 ng/mL if >50 years) combined with an unlikely pre-test probability (PTP) can increase the proportion of older patients in whom pulmonary embolism (PE) can be safely excluded, but the IL D-dimer HS assay was not assessed. To assess the ability of the IL D-dimer HS assay to exclude PE using the AADD. METHODS Retrospective analysis of consecutive patients presenting with symptoms of acute PE to one of three Monash Health Emergency Departments (January 2013-January 2014) who had computed tomography pulmonary angiography. In the group with D-dimer, efficiency (proportion of PE excluded based on a combination of unlikely PTP and negative D-dimer) was determined using (i) current laboratory (200 ng/mL), (ii) conventional (230 ng/mL) and (iii) modified (375 ng/mL if age ≥60 years) AADD cut-offs. RESULTS A total of 176 patients with D-dimers was included (mean age = 58.5 years; 54.0% males; 71.0% age >50 years). Prevalence of PE in the overall, unlikely and likely PTP groups, was 17.0, 13.0 and 24.6% respectively. In the unlikely PTP group (115 patients), efficiency for the current, conventional, modified and AADD cut-offs was 9.6, 24.3, 30.4 and 37.4% respectively. CONCLUSION The absolute increase in efficiency of an AADD compared to conventional cut-off using the IL D-dimer HS assay is modest (~10%) and requires prospective validation. Modifying our cut-off to 230 ng/mL and systematic implementation of a clinical algorithm, including D-dimer testing and PTP, is likely a more important first step.
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Affiliation(s)
- Ming S Lim
- Haematology Department, Monash Medical Centre, Melbourne, Victoria, Australia
| | - Ashwini Bennett
- Haematology Department, Monash Medical Centre, Melbourne, Victoria, Australia
| | - Sanjeev Chunilal
- Haematology Department, Monash Medical Centre, Melbourne, Victoria, Australia.,Department of Medicine, Monash University, Melbourne, Victoria, Australia
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Age-adjusted D-dimer thresholds in the investigation of suspected pulmonary embolism: A retrospective evaluation in patients ages 50 and older using administrative data. CAN J EMERG MED 2018; 20:725-731. [DOI: 10.1017/cem.2018.389] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
AbstractObjectivesD-dimer testing is an important component of the workup for pulmonary embolism (PE). However, age-related increases in D-dimer concentrations result in false positives in older adults, leading to potentially unnecessary imaging utilization. The objective of this study was to quantify the test characteristics of an age-adjusted D-dimer cut-off for ruling out PE in older patients investigated in actual clinical practice.MethodsThis observational study used administrative data from four emergency departments from July 2013 to January 2015. Eligible patients were ages 50 and older with symptoms of PE who underwent D-dimer testing. The primary outcome was 30-day diagnosis of PE, confirmed by imaging reports. Test characteristics of the D-dimer assay were calculated using the standard reference value (500 ng/ml), the local reference value (470 ng/ml), and an age-adjusted threshold (10 ng/ml × patient’s age).ResultsThis cohort includes 6,655 patients ages 50 and older undergoing D-dimer testing for a possible PE. Of these, 246 (3.7%) were diagnosed with PE. Age-adjusted D-dimer cut-offs were more specific than standard cut-offs (75.4% v. 63.8%) but less sensitive (90.3% v. 97.2%). The false-negative risk in this population was 0.49% using age-adjusted D-dimer cut-offs compared with 0.15% with traditional cut-offs.ConclusionAge-adjusted D-dimer cut-offs are substantially more specific than traditional cut-offs and may reduce CT utilization among older patients with suspected PE. We observed a loss of sensitivity, with an increased risk of false-negatives, using age-adjusted cut-offs. We encourage further evaluation of the safety and accuracy of age-adjusted D-dimer cut-offs in actual clinical practice.
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Bai J, Bai F, Zhu H, Xue D. The perceived and objectively measured effects of clinical pathways' implementation on medical care in China. PLoS One 2018; 13:e0196776. [PMID: 29734350 PMCID: PMC5937784 DOI: 10.1371/journal.pone.0196776] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Accepted: 04/19/2018] [Indexed: 12/29/2022] Open
Abstract
Introduction Substantial resources have been expended on clinical pathways (CPs), but the reported effects of CPs on medical care vary considerably. This study sought to determine the effects of CPs on medical care in Chinese hospitals, including the perceived effects of CPs on medical care and the objectively measured patient outcomes. Methods Study data were obtained from 54 public hospitals in three provinces of China in 2015. Hospital questionnaires, employee surveys, and chart reviews were used to collect data related to hospital characteristics, the implementation of CPs and compliance status, perceived effects of CPs, and objectively measured patient outcomes. Logistic regression models and linear regression models were adopted in this study. Results The effects of CPs were not highly perceived by the hospitals or by the managers and physicians in China. The relatively low involvement in the implementation of and adherence to CPs resulted in CPs having no significant effects on hospital medical care as a whole. However, a chart review of 5 conditions in Chinese hospitals demonstrated that compliance with national CPs reduced the length of stay (LOS) and inpatient medical costs. Conclusions CPs should be implemented widely and followed closely to improve hospital medical care as a whole, and further studies should be conducted to identify the key elements of the effects of CPs on patient clinical outcomes.
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Affiliation(s)
- Jie Bai
- Department of Hospital Management, School of Public Health, Key Laboratory of Health Technology Assessment, National Health Commission (Fudan University), Fudan University, Shanghai, P.R. China
| | - Fei Bai
- Center for Medical Service Administration, National Health Commission of China, Beijing, P.R. China
| | - Hongbo Zhu
- Medical Administration and Management, Health and Family Planning Commission of Hubei Province, Wuhan, P.R. China
| | - Di Xue
- Department of Hospital Management, School of Public Health, Key Laboratory of Health Technology Assessment, National Health Commission (Fudan University), Fudan University, Shanghai, P.R. China
- * E-mail:
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Rehman A, Yelf E, Pearson J, Yeo W. Compliance to clinical pathways in the management of suspected pulmonary embolus: are there cost implications? Intern Med J 2017; 47:458-461. [DOI: 10.1111/imj.13387] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2016] [Revised: 10/11/2016] [Accepted: 10/12/2016] [Indexed: 11/27/2022]
Affiliation(s)
- Ata Rehman
- Division of General Medicine; Wollongong and Shellharbour Hospital; Wollongong New South Wales Australia
- Illawarra Health and Medical Research Institute; Wollongong New South Wales Australia
| | - Eric Yelf
- Division of General Medicine; Wollongong and Shellharbour Hospital; Wollongong New South Wales Australia
| | - Jacqueline Pearson
- Division of General Medicine; Wollongong and Shellharbour Hospital; Wollongong New South Wales Australia
| | - Wilf Yeo
- Division of General Medicine; Wollongong and Shellharbour Hospital; Wollongong New South Wales Australia
- Illawarra Health and Medical Research Institute; Wollongong New South Wales Australia
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Sud R, Langfield J, Chu G. Heightened clinical suspicion of pulmonary embolism and disregard of the D-dimer assay: a contemporary trend in an era of increased access to computed tomography pulmonary angiogram? Intern Med J 2014; 43:1231-6. [PMID: 23800111 DOI: 10.1111/imj.12225] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2013] [Accepted: 06/13/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND Prospective studies have shown that utilising qualitative D-dimers in those with a low Wells pre-test probability (PTP) of pulmonary embolism (PE) have significantly reduced the number of computed tomography pulmonary angiograms (CTPA) being performed. These studies have been based on a PE prevalence of approximately 6% in the low PTP group. AIM This study compares the diagnostic approach to PE in the study institution to well-established guidelines. The study also re-examines the cost-benefit analyses of qualitative d-dimers and CTPA in the low PTP group. METHODS A retrospective study of 169 consecutive CTPA requested in the emergency department of a major teaching hospital during a 12-month period. RESULTS The prevalence of PE was 0% (0/65), 11.7% (9/77) and 0% (0/2) in the low, moderate and high Wells PTP groups respectively, and 6.3% (9/144) overall. PTP was documented in 10 (6.9%) cases, and the qualitative Clearview Simplify D-dimer was only ordered in 33.8% (22/65) of low PTP subjects. The false positive D-dimer rate was 90.2% (37/41). Cost-benefit analysis and assay performance defines a narrow range of low PTP PE prevalence between 1% and 5% for the utilisation of the qualitative D-dimer assay. CONCLUSIONS The overall prevalence of PE in subjects undergoing CTPA was significantly lower compared with data in the literature. The authors recommend warranted clinical suspicion of PE should be confirmed by a senior physician prior to placing a patient in the PE work-up pathway. In such patients, the qualitative D-dimer assay should be utilised if PTP is low, and the exclusionary efficiency of the D-dimer will be improved in the setting of higher PE prevalence in this subgroup. Hospitals should audit local PE prevalence, as cost-benefit analyses raises questions about the effectiveness of D-dimers when PE prevalence is very low in the low PTP subgroup.
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Affiliation(s)
- R Sud
- Resident Support Unit, Westmead Hospital, Sydney, New South Wales, Australia
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Martin JH, Kubler P. Treatment for pulmonary hypertension in Australia: too far too fast? Intern Med J 2011; 41:217-9. [DOI: 10.1111/j.1445-5994.2011.02437.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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