title: Application of a decision rule and a D-dimer assay in the diagnosis of pulmonary embolism.
abstract: Current strategies for diagnosing pulmonary embolism (PE) include a clinical decision rule (CDR), followed by a D-dimer assay in patients with an unlikely clinical probability. We assessed the implementation of the current guidelines for the diagnosis of PE. A first questionnaire was sent to internists and pulmonologists to assess the proportion of physicians that adequately applied the guidelines. Two versions of a second questionnaire were sent presenting five hypothetical cases of which in two cases with an intermediate clinical probability an abnormal D-dimer test result was added to one version. We assessed the variation of the CDR and compared the proportions of a likely clinical probability between the two versions. A total of 65 physicians responded to the first questionnaire (response rate 75%). Half of the physicians (N=29; 46%) indicated that they use a CDR in all patients and 22 physicians (45%) indicated that they review the D-dimer result after they examined patients. Sixty-two physicians responded on the second questionnaire (response rate 36%). A shift was observed from an unlikely to a likely probability when an abnormal D-dimer test result was added to the clinical information (22% to 41%; p=0.22 and 26% to 50%; p<0.05). Our findings indicate that physicians do not use the guidelines for diagnosis of PE consistently. Furthermore, the knowledge of an abnormal D-dimer test result before seeing the patient leads to a higher CDR score. Physicians should therefore first examine patients before taking note of the D-dimer test result.
authors.affiliation: Department of Vascular Medicine, Academical Medical Center, Amsterdam, The Netherlands. n.s.gibson@amc.uva.nl
authors.forename: Nadine S
authors.initials: NS
authors.lastname: Gibson
authors.forename: Renee A
authors.initials: RA
authors.lastname: Douma
authors.forename: Alessandro
authors.initials: A
authors.lastname: Squizzato
authors.forename: Maaike
authors.initials: M
authors.lastname: Söhne
authors.forename: Harry R
authors.initials: HR
authors.lastname: Büller
authors.forename: Victor E A
authors.initials: VE
authors.lastname: Gerdes
mesh_terms: D000328:Adult; D015415:Biomarkers / Q000097:blood; D002983:Clinical Competence; D003661:Decision Support Techniques; D005260:Female; D005338:Fibrin Fibrinogen Degradation Products / Q000032:analysis*; D019983:Guideline Adherence; D019538:Health Care Surveys; D006801:Humans; D008297:Male; D008875:Middle Aged; D017410:Practice Guidelines as Topic; D010818:Practice Patterns, Physicians'; D011237:Predictive Value of Tests; D011655:Pulmonary Embolism / Q000097:blood / Q000175:diagnosis* / Q000628:therapy; D018570:Risk Assessment; D011795:Surveys and Questionnaires; D015854:Up-Regulation
chemical_list: D015415:Biomarkers; D005338:Fibrin Fibrinogen Degradation Products; C036309:fibrin fragment D