Rationale and Objectives
To assess the pretest practices of US clinicians who treat patients with acute pulmonary embolism (PE).
Materials and Methods
We surveyed 855 practicing physicians selected randomly from three professional organizations. We asked participants to estimate how often and by what method they determine the likelihood of PE before they request confirmatory studies. Participants reported their awareness of four published clinical practice guidelines dealing with acute PE and selected options for further diagnostic testing after reviewing clinical data from three hypothetical patients presenting with low, intermediate, and high probability of acute PE.
Results
We received completed surveys from 240 physicians practicing in 44 states. Although most (98.3%) report that they assess pretest probability of PE before testing, slightly more than half do so routinely. A total of 72.5% prefer an unstructured approach to pretest assessment, whereas 22.9% use published prediction rules. Most (93.0%) are aware of at least one published guideline for assessing acute PE, but only 44.2% report using one or more in daily practice. Respondents who use published prediction rules, estimate pretest probability routinely, or use at least one practice guideline were more likely to request additional testing when reviewing a low probability clinical scenario. No differences in testing frequency or preferences were observed for intermediate or high probability clinical scenarios.
Conclusions
The majority of clinicians we surveyed use an unstructured approach when estimating the pretest probability of acute PE. With the exception of low probability scenario, clinicians agreed on testing choices in suspected acute PE, regardless of the method or frequency of pre-test assessment.
Acute pulmonary embolism (PE) is a common, potentially lethal, but treatable condition with protean clinical manifestations ( ). Accurate and timely diagnosis of PE is essential because both the over- and undertreatment of acute PE carries significant risk ( ). Because the prevalence of PE in patient populations in whom it is suspected varies widely and may be as low as 18% ( ), the appropriate selection of patients for diagnostic imaging can be challenging. The recent increased use of diagnostic imaging, particularly computed tomography (CT) pulmonary angiography in hospitalized and emergency department patients suggests that clinicians are lowering their threshold for requesting confirmatory radiologic testing in acute PE ( ). A simple and effective means of clinical risk assessment to guide subsequent, expensive diagnostic testing would be useful ( ).
Three models for clinical pretest risk assessment in acute PE have been proposed: the Canadian model of Wells and others ( ), the Geneva model ( ), and the Pisa model ( ). Each of these methods assigns patients to low-, intermediate-, or high-risk categories based on history, clinical findings, and chest radiography. After the PE risk is defined, published practice guidelines can be applied to direct subsequent confirmatory laboratory and radiological testing ( ). Although the utility of such clinical prediction rules in patients with suspected acute PE has been studied and validated ( ), it is not known whether US physicians regularly use them in practice. In the case of PE, physicians may prefer to base pretest assessment on their own unstructured judgment ( ), even though such “gestalt” impressions suffer from inadequate interobserver reliability ( ). In addition, it is not known whether clinicians are aware of and adhere to published guidelines when evaluating patients with suspected acute PE.
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Materials and methods
Study Population and Sample Size
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Survey Instrument
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Physician and Practice Characteristics
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Method and Frequency of Estimating the Pretest Probability of PE
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Awareness of Specific Practice Guidelines
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Clinical Scenarios
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Survey Method
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Data Analysis
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Results
Survey Responses
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Method and Frequency of Pretest Assessment
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Table 1
Method of Estimating the Pretest Risk Assessment in Acute PE ⁎
Characteristic (Number) Standardized Prediction Rules (With 3-Group Stratification) † Unstructured “Gestalt” Approach (With 3-Group Stratification) ‡ Unstructured “Gestalt” Approach (With 2-Group Stratification) § Never ¶ Other Method Number (%) Number (%) Number (%) Number (%) Number (%) All respondents ( n = 239) 55 (22.9) 128 (53.3) 46 (19.2) 4 (1.7) 6 (2.5) Emergency medicine physicians ( n = 84) 21 (25.0) 43 (51.2) 14 (16.7) 2 (2.4) 4 (4.8) Pulmonologists ( n = 77) 15 (19.5) 48 (62.3) 14 (18.2) 0 (0) 0 (0) General internists ( n = 78) 19 (24.1) 37 (48.8) 18 (22.8) 2 (2.5) 2 (2.6) Practice: Nonacademic ( n = 204) 44 (21.5) 110 (53.7) 40 (19.5) 4 (2.0) 6 (2.9) Academic ( n = 35) 11 (31.4) 18 (51.4) 6 (17.1) 0 (0) 0 (0) Proportion of time spent in direct patient care activities ≤75% ( n = 53) 16 (29.6) 25 (46.3) 10 (18.5) 0 (0) 2 (3.8) ≥76% ( n = 178) 38 (21.4) 98 (55.1) 35 (19.7) 4 (2.3) 3 (1.7) Proportion of time devoted to caring for hospitalized inpatients: ≤50% ( n = 174) 41 (23.4) 90 (51.4) 33 (18.9) 4 (2.3) 6 (3.4) ≥51% ( n = 64) 14 (21.9) 37 (57.8) 13 (20.3) 0 (0) 0 (0) Patients with possible acute PE encountered in practice: ≤4/month ( n = 127) 28 (21.9) 66 (51.6) 25 (19.5) 3 (2.3) 5 (3.9) ≥5/month ( n = 110) 27 (24.6) 60 (54.6) 21 (19.1) 1 (0.9) 1 (0.9) Residency completed: Before 1990 ( n = 159) 33 (20.6) 87 (54.4) 31 (19.4) 4 (2.5) 4 (2.5) After 1989 ( n = 75) 20 (26.7) 38 (50.7) 15 (20.0) 0 (0) 2 (2.7)
PE: pulmonary embolism.
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Table 2
Frequency with which Pretest Risk Assessment is Estimated ⁎
Characteristic (Number) Very Frequent † Number (%) Frequent † Number (%) Infrequent † Number (%) All respondents ( n = 228) 125 (54.8) 63 (27.6) 40 (17.5) Emergency medicine physicians ( n = 79) 47 (59.5) 19 (24.1) 13 (16.5) Pulmonologists ( n = 75) 46 (61.3) 20 (26.7) 9 (12.0) General internists ( n = 74) 32 (43.2) 24 (32.4) 18 (24.3) Practice: Nonacademic ( n = 195) 102 (52.3) 54 (27.7) 39 (20.0) Academic ( n = 33) 23 (69.7) 9 (27.3) 1 (3.0) Proportion of time spent in direct patient care activities ≤75% ( n = 50) 32 (64.0) 14 (28.0) 4 (8.0) ≥76% ( n = 171) 91 (53.2) 46 (26.9) 34 (19.9) Proportion of time devoted to caring for hospitalized inpatients: ≤50% ( n = 164) 83 (50.6) 48 (29.3) 33 (20.1) ≥51% ( n = 63) 42 (66.7) 14 (22.2) 7 (11.1) Patients with possible acute PE encountered in practice: ≤4/month ( n = 120) 62 (51.7) 35 (29.2) 23 (19.2) ≥5/month ( n = 106) 62 (58.5) 27 (25.5) 17 (16.0) Residency completed: Before 1990 ( n = 153) 90 (58.8) 43 (28.1) 20 (13.1) After 1989 ( n = 72) 32 (44.4) 20 (27.8) 20 (27.8)
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Awareness of Published Practice Guidelines
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Table 3
Awareness of Published Guidelines ⁎
Total Responses n = 240 Pulmonologists n = 77 General Internists n = 79 Emergency Medicine Physicians n = 84 Guidelines Response Option Number (%) Number (%) Number (%) Number (%) American Thoracic Society (Guidelines) † Use it in my practice 42 (17.5) 28 (36.4) 10 (12.7) 4 (4.8) Have read it 69 (28.8) 35 (45.5) 19 (24.1) 15 (17.9) Aware of it 66 (27.5) 8 (10.4) 27 (34.2) 31 (36.9) Not aware of it 63 (26.3) 6 (7.8) 23 (29.1) 34 (40.5) Fedullo and Tapson: The Evaluation of Suspected Pulmonary Embolism (review article) ‡ Use it in my practice 48 (20.0) 15 (19.5) 19 (24.1) 14 (16.7) Have read it 73 (30.4) 37 (48.1) 19 (24.1) 17 (20.2) Aware of it 59 (24.6) 18 (23.4) 20 (25.3 21 (25.0) Not aware of it 60 (25.0) 7 (9.1) 21 (26.6) 32 (31.1) The American College of Emergency Physicians (guidelines) § Use it in my practice 43 (17.9) 0 (0) 3 (3.8) 40 (47.6) Have read it 33 (13.8) 4 (5.2) 1 (1.3) 28 (33.3) Aware of it 41 (17.1) 18 (23.4) 12 (15.2) 11 (13.1) Not aware of it 122 (50.8) 54 (70.1) 63 (79.8) 5 (6.0) British Thoracic Society (guidelines) ¶ Use it in my practice 10 (4.2) 3 (3.9) 4 (5.1) 3 (3.6) Have read it 10 (4.2) 6 (7.8) 1 (1.3) 3 (3.6) Aware of it 39 (16.3) 14 (18.2) 14 (17.7) 11 (13.1) Not aware of it 180 (75.0) 53 (68.8) 60 (76.0) 67 (79.8) Any of the above Use it in my practice 106 (44.2) 35 (45.5) 27 (34.2) 44 (52.4) Have read it 87 (36.3) 36 (46.8) 25 (31.7) 26 (31.0) Aware of it 30 (12.5) 5 (6.5) 15 (19.0) 10 (11.9) Not aware of it 17 (7.1) 1 (1.3) 12 (15.2) 4 (4.8)
PE: pulmonary embolism.
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Performance on Hypothetical Clinical Scenarios
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Table 4a
Scenario Performance versus Method of Pretest Assessment
Scenario Type Response Option Total Responses (Weekdays) Total Responses (Nights/Weekends) Total Responses (with additional findings) Standardized Prediction Rules (with 3 group stratification) † Unstructured “Gestalt” Method (with 3 group stratification) ‡ Unstructured “Gestalt” Method (with 2 group stratification) § Number (%) Number (%) Number (%) Number (%) Number (%) Number (%) Findings = left lower lobe infiltrate Low probability_n_ = 238n = 238n = 238n = 54n = 128n = 46 No testing 118 (49.6) 104 (43.7) 170 (71.43) 19 (35.2) 68 (53.1) 24 (52.2) D-dimer 68 (28.6) 70 (29.4) 31 (13.0) 19 (35.2) 37 (28.9) 10 (21.7) CTPA 34 (14.3) 42 (17.7) 28 (11.8) 10 (18.5) 17 (13.3) 6 (13.0) VIP 13 (5.5) 12 (5.0) 6 (2.5) 5 (9.3) 5 (3.9) 3 (6.5) Other ⁎ 5 (2.1) 10 (4.2) 3 (1.3) 1 (1.9) 1 (0.8) 3 (6.5) Findings = pleural effusions and pulmonary vascular congestion Intermediate probability_n_ = 239n = 239n = 233n = 55n = 128n = 45 No testing 8 (3.4) 10 (4.2) 37 (15.9) 1 (1.8) 2 (1.6) 3 (6.7) D-dimer 29 (12.1) 34 (14.2) 28 (12.0) 7 (12.7) 15 (11.7) 6 (13.3) CTPA 154 (64.4) 167 (69.9) 119 (51.1) 35 (63.6) 87 (68.0) 26 (57.8) VIP 27 (11.3) 19 (8.0) 10 (4.3) 7 (12.7) 14 (10.9) 6 (13.3) Other ⁎ 21 (8.8) 9 (3.8) 39 (16.7) 5 (9.1) 10 (7.8) 4 (8.9) Findings = pleural effusion High probability_n_ = 239n = 239n = 239n = 55n = 128n = 45 No testing 0 (0) 2 (0.8) 3 (1.3) 0 (0) 0 (0) 0 (0) D-dimer 13 (5.4) 18 (7.5) 9 (3.8) 3 (5.4) 7 (5.5) 2 (4.4) CTPA 176 (73.6) 187 (78.2) 201 (84.1) 40 (72.7) 96 (75.0) 33 (73.3) VIP 38 (15.9) 24 (10.0) 13 (5.4) 7 (12.7) 21 (16.4) 9 (20.0) Other ⁎ 12 (5.0) 8 (3.4) 13 (5.4) 5 (9.1) 4 (3.1) 1 (2.2)
CTPA: computed tomography pulmonary angiography; VIP: ventilation perfusion scanning.
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Table 4b
Scenario Performance versus Frequency of Pretest Assessment and Awareness of Guidelines
Scenario Type Response Option Very Frequent † Frequent † Infrequent † Uses any Guideline Does not use any Guideline Number (%) Number (%) Number (%) Low probability_n_ = 124n = 63n = 39n = 106n = 133 No testing 53 (42.7) 36 (57.1) 22 (56.4) 42 (40.0) 76 (57.1) D-dimer 48 (38.7) 11 (17.5) 7 (18.0) 37 (35.2) 31 (23.3) CTPA 13 (10.5) 11 (17.5) 7 (18.0) 17 (16.2) 17 (12.8) VIP 7 (5.7) 4 (6.3) 2 (5.1) 7 (6.7) 6 (4.5) Other ⁎ 3 (2.4) 1 (1.6) 1 (2.6) 2 (1.9) 3 (2.3) Intermediate probability_n_ = 124n = 63n = 40n = 106n = 133 No testing 1 (0.8) 3 (4.8) 3 (7.5) 5 (4.7) 3 (2.3) D-dimer 14 (11.2) 5 (7.9) 10 (25.0) 11 (10.4) 18 (13.5) CTPA 87 (70.2) 40 (63.5) 19 (47.5) 76 (71.7) 78 (58.7) VIP 14 (11.3) 8 (12.7) 4 (10.0) 8 (7.6) 19 (14.3) Other ⁎ 8 (6.5) 7 (11.1) 4 (10.0) 6 (5.7) 15 (11.3) High probability_n_ = 124n = 63n = 40n = 106n = 133 No testing 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) D-dimer 6 (4.8) 2 (3.2) 4 (10.0) 5 (4.7) 8 (6.0) CTPA 92 (74.2) 48 (76.2) 27 (67.5) 82 (77.4) 94 (70.7) VIP 18 (14.5) 12 (19.1) 7 (17.5) 13 (12.3) 25 (18.8) Other ⁎ 8 (6.5) 1 (1.6) 2 (5.0) 6 (5.7) 6 (4.5)
CTPA: computed tomography pulmonary angiography; VIP: ventilation perfusion scanning.
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Discussion
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Acknowledgments
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Appendix 1
Hypothetical clinical scenarios
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