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Combination pretest probability assessment and D-dimer did not reduce outpatient imaging for venous thromboembolism in a tertiary care hospital emergency department

Published online by Cambridge University Press:  04 March 2015

Sarah Ingber ,
Rita Selby ,
Jacques Lee ,
William Geerts  and
Elena Brnjac
Sarah Ingber
Affiliation:
Division of Hematology, University of Toronto
Rita Selby*
Affiliation:
Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON Department of Clinical Pathology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON
Jacques Lee
Affiliation:
Department of Emergency Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON
William Geerts
Affiliation:
Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON
Elena Brnjac
Affiliation:
Department of Clinical Pathology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON
*
Coagulation Laboratories, Sunnybrook Health Sciences Centre and University Health Network, D-675a, 2075 Bayview Avenue, Toronto, ON M4N 3M5; rita.selby@sunnybrook.ca

Abstract

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Introduction:

Venous thromboembolism (VTE) is difficult to diagnose yet potentially life threatening. A low-risk pretest probability (PTP) assessment combined with a negative Ddimer can rule out VTE in two-thirds of outpatients, reducing the need for imaging. Real-life implementation of this strategy is associated with several challenges.

Methods:

We evaluated the impact of introducing a standardized diagnostic algorithm including a mandatory PTP assessment and D-dimer on radiologic test use for VTE in our emergency department (ED). A retrospective review of all ED visits for suspected VTE in the year prior to and following the introduction of this algorithm was conducted. VTE diagnosis was based on imaging. Guideline compliance was also assessed.

Results:

ED visits were investigated for suspected VTE in the pre- and postintervention periods (n 5 1,785). Most D-dimers (95%) ordered were associated with a PTP assessment, and 50% of visits assigned a low PTP had a negative D-dimer. The proportion of imaging tests ordered for VTE in all ED visits was unchanged postintervention (1.9% v. 2.0%). The proportion of patients with suspected VTE in whom VTE was confirmed on imaging decreased postintervention (10.2% v. 14.1%).

Conclusion:

In spite of excellent compliance with our algorithm, we were unable to reduce imaging for VTE. This may be due to a lower threshold for suspecting VTE and an increase in investigation for VTE combined with a high false positive rate of our D-dimer assay in low–pretest probability patients. This study highlights two common real-life challenges with adopting this strategy for VTE investigation.

Keywords

D-dimerquality improvementvenous thromboembolism
Type
Original Research • Recherche originale
Information
Canadian Journal of Emergency Medicine , Volume 16 , Issue 1 , January 2014 , pp. 53 - 62
Copyright
Copyright © Canadian Association of Emergency Physicians 2014

References

REFERENCES

1.Le Gal, G, Bounameaux, H.Diagnosing pulmonary embolism: running after the decreasing prevalence of cases among suspected patients. J Thromb Haemost 2004;2:1244–6, doi:10.1111/j.1538-7836.2004.00795.x.CrossRefGoogle ScholarPubMed
2.Wells, PS, Anderson, DR, Bormanis, J, Guy, F, et al. Value of assessment of protest probability of deep vein thrombosis in clinical management. Lancet 1997;350:1795–8, doi:10.1016/S0140-6736(97)08140-3.Google Scholar
3.Wells, PS, Ginsberg, JS, Anderson, DR, et al. Use of a clinical model for safe management of patients with suspected pulmonary embolism. Ann Intern Med 1998;129:997–1005, doi:10.7326/0003-4819-129-12-199812150-00002.CrossRefGoogle ScholarPubMed
4.Wicki, J, Perneger, TV, Junod, AF, et al. Assessing clinical probability of pulmonary embolism in the emergency ward: a simple score. Arch Intern Med 2001;161:92–7, doi:10.1001/archinte.161.1.92.Google Scholar
5.Wells, PS, Anderson, DR, Rodger, M, et al. Evaluation of D-dimer in the diagnosis of suspected deep vein thrombosis. N Engl J Med 2003;349:1227–35, doi:10.1056/NEJMoa023153.Google Scholar
6.Wells, PS, Anderson, DR, Rodger, M, et al. Excluding pulmonary embolism at the bedside without diagnostic imaging: management of patients with suspected pulmonary embolism presenting to the emergency department by using a simple clinical model and D-dimer. Ann Intern Med 2001;135:98–107, doi:10.7326/0003-4819-135-2-200107170-00010.CrossRefGoogle Scholar
7.Ten Cate-Hoek, AJ, Prins, MH.Management studies using a combination of D-dimer test result and clinical probability to rule out venous thromboembolism: a systematic review. J Thromb Haemost 2005;3:2465–70, doi:10.1111/j.1538-7836.2005.01556.x.CrossRefGoogle ScholarPubMed
8.Perone, N, Bounameaux, H, Perrier, A.Comparison of four strategies for diagnosing deep vein thrombosis: a cost effectiveness analysis. Am J Med 2000;110:33–40, doi:10.1016/S0002-9343(00)00598-2.CrossRefGoogle Scholar
9.Lebrun, E, Maitre, B, Grenier-Sennelier, C, et al. Effect of Ddimer testing on the diagnostic strategy of suspected pulmonary embolism: an observational study of practice patterns and costs.Eur Radiol 2000;10 Suppl 3:S433–4, doi:10.1007/PL00014119.Google Scholar
10.Durieux, P, Dhote, R, Meyniard, O, et al. D-dimer testing as the initial test for suspected pulmonary embolism. Appropriateness of prescription and physician compliance to guidelines. Thromb Res 2001;101:261–6, doi:10.1016/S0049-3848(00)00407-2.CrossRefGoogle ScholarPubMed
11.Goldstein, N, Kollef, MH, Ward, S, et al. The impact of the introduction of a rapid D-dimer assay on the diagnostic evaluation of suspected pulmonary embolism. Arch Intern Med 2001; 161:567–71, doi:10.1001/archinte.161.4.567.Google Scholar
12.Blais, N, Morais, J, Sauve, N, et al. Time trends in the usefulness of pre-test prediction and D-dimer testing for the diagnosis of venous thromboembolism [abstract]. ASH Annual Meeting Abstracts, Part 1, 2006;108:943a. In: ASH; 2007.Google Scholar
13.Teismann, NA, Cheung, PT, Frazee, B.Is the ordering of imaging for suspected venous thromboembolism consistent with D-dimer result? Ann Emerg Med 2009;54:442–6, doi:10.1016/j.annemergmed.2009.03.017.CrossRefGoogle ScholarPubMed
14.Weiss, CR, Haponik, EF, Diette, GB, et al. Pretest risk assessment in suspected acute pulmonary embolism. Acad Radiol 2008;15:3–14.Google Scholar
15.Smith, C, Mensah, A, Mal, S, et al. Is pretest probability assessment on emergency department patients with suspected venous thromboembolism documented before SimpliRED D-dimer testing? CJEM 2008;10:519–23.Google ScholarPubMed
16.Girard, P, Ratana, S, Cosserat, J, et al. Futile D-dimer testing in hospitalized patients – description, interpretation, improvements. Thromb Haemost 2008;100:1209–11.Google ScholarPubMed
17.Douma, RA, Le Gal, G, Sohne, M.Potential of an ageadjusted D-dimer cut-off value to improve the exclusion of pulmonary embolism in older patients: a retrospective analysis of three large cohorts. BMJ 2010;340:c1475, doi:10.1136/bmj.c1475.Google Scholar
18.Prologo, JD, Gilkeson, RC, Diaz, M, et al. CT pulmonary angiography: a comparative analysis of the utilization patterns in emergency department and hospitalized patientsbetween 1998-2003. AJR Am J Roentgenol 2004;182:1093–6, doi:10.2214/ajr.183.4.1831093.CrossRefGoogle Scholar
19.Corwin, M, Donohoo, J, Partridge, R, et al. Do emergency physicians use serum D-dimer effectively to determinethe need for CT when evaluating patients for pulmonary embolism? Review of 5344 consecutive patients. AJR Am J Roentgenol 2009;192:1319–23, doi:10.2214/AJR.08.1346.CrossRefGoogle Scholar