Appropriateness of Diagnostic Management and Outcomes of Suspected Pulmonary Embolism

7 February 2006 | Volume 144 Issue 3 | Pages 157-164

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.

Editors' Notes Context A large body of high-quality medical literature supports guidelines for diagnosing pulmonary embolism. Content The authors studied 1529 patients with suspected pulmonary embolism who presented to 117 emergency departments. They compared each patient's data and the treating physician's final diagnosis with prespecified diagnostic criteria. When they diagnosed pulmonary embolism, physicians used appropriate diagnostic criteria in 92% of patients. When they ruled out pulmonary embolism, they used appropriate diagnostic criteria in only 43% of patients. Inappropriate management was strongly associated with thromboembolic events in a 3-month follow-up period. Interpretation Failure to adhere to diagnostic guidelines for pulmonary embolism has consequences. Inappropriate management occurs more often when ruling out the condition. —The Editors

 

Author and Article 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).

Potential Financial Conflicts of Interest: None disclosed.

Requests for Single Reprints: 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, PMRoy{at}chu-angers.fr.

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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