Background: Different diagnostic strategies exist to manage patients with suspected pulmonary embolism (PE) and their performance may vary depending on the setting or overall PE prevalence where they are used in.
Aims: To assess the performance of strategies for the diagnosis of acute PE in patients across various healthcare settings and explore the impact of PE prevalence on these estimates.
Methods: Systematic review followed by an individual patient data meta-analysis (IPD-MA) using data from 23 different international studies of patients with suspected acute PE from diverse settings, including self-referral emergency care (N=12,612), primary healthcare (N=3,174), referred patients to a hospital-care setting (N=17,952), and from hospitalized or nursing homes patients (N=2,410). Multilevel logistic regression models were used to estimate the PE probability in patients categorized as ‘PE considered excluded’ by each strategy, referred to as the ‘diagnostic failure rate’. Similarly, efficiency of each strategy was defined as the probability of being classified as ‘PE considered excluded’ without imaging tests.
Results: As depicted in Figure 1, the accuracy of all diagnostic strategies varied across healthcare setting. For strategies combining a clinical decision rule with D-dimer testing, interpretation of D-dimer adjusted to clinical pre-test probability (CPTP) showed highest efficiency in all healthcare settings. Conversely, the failure rate of strategies adjusting D-dimer to CPTP was higher compared to strategies adjusting D-dimer to age or using a fixed cut-off, notably in referred hospital-care. Finally, the failure rate of all strategies was highest in hospitalized or institutionalized patients. Increasing PE prevalence resulted in an increase in the diagnostic failure rate (see Figure 2).
Conclusions: The diagnostic performance of available diagnostic strategies for suspected PE differed substantially across healthcare settings or PE prevalence. These findings may inform physicians when deciding about what strategy to use in their healthcare setting, balancing the trade-off between the diagnostic failure rate and efficiency of available strategies.
To cite this abstract in AMA style:Geersing G-, Takada T, Klok FA, Büller HR, Courtney DM, Freund Y, Le Gal G, Ghanima W, Kline JA, Huisman MV, Moons KG, Parpia S, Righini M, Roy P-, van Smeden M, Stals MA, Wells PS, de Wit K, Kraaijpoel N, van Es N. Diagnosis of Acute Pulmonary Embolism across Different Healthcare Settings: A Systematic Review and Individual Patient Data Meta-analysis [abstract]. Res Pract Thromb Haemost. 2021; 5 (Suppl 1). https://abstracts.isth.org/abstract/diagnosis-of-acute-pulmonary-embolism-across-different-healthcare-settings-a-systematic-review-and-individual-patient-data-meta-analysis/. Accessed September 24, 2021.
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