title: External validation of prognostic rules for early post-pulmonary embolism mortality: assessment of a claims-based and three clinical-based approaches.
abstract: BACKGROUND
  Studies show the In-hospital Mortality for Pulmonary embolism using Claims daTa (IMPACT) rule can accurately identify pulmonary embolism (PE) patients at low-risk of early mortality in a retrospective setting using only claims for the index admission. We sought to externally validate IMPACT, Pulmonary Embolism Severity Index (PESI), simplified PESI (sPESI) and Hestia for predicting early mortality.
  
  
  METHODS
  We identified consecutive adults admitted for objectively-confirmed PE between 10/21/2010 and 5/12/2015. Patients undergoing thrombolysis/embolectomy within 48 h were excluded. All-cause in-hospital and 30 day mortality (using available Social Security Death Index data through January 2014) were assessed and prognostic accuracies of IMPACT, PESI, sPESI and Hestia were determined.
  
  
  RESULTS
  Twenty-one (2.6 %) of the 807 PE patients died before discharge. All rules classified 26.1-38.3 % of patients as low-risk for early mortality. Fatality among low-risk patients was 0 % (sPESI and Hestia), 0.4 % (IMPACT) and 0.6 % (PESI). IMPACT's sensitivity was 95.2 % (95 % confidence interval [CI] = 74.1-99.8 %), and the sensitivities of clinical rules ranged from 91 (PESI)-100 % (sPESI and Hestia). Specificities of all rules ranged between 26.8 and 39.1 %. Of 573 consecutive patients in the 30 day mortality analysis, 33 (5.8 %) died. All rules classified 27.9-38.0 % of patients as low-risk, and fatality occurred in 0 (Hestia)-1.4 % (PESI) of low-risk patients. IMPACT's sensitivity was 97.0 % (95%CI = 82.5-99.8 %), while sensitivities for clinical rules ranged from 91 (PESI)-100 % (Hestia). Specificities of rules ranged between 29.6 and 39.8 %.
  
  
  CONCLUSIONS
  In this analysis, IMPACT identified low-risk PE patients with similar accuracy as clinical rules. While not intended for prospective clinical decision-making, IMPACT appears useful for identification of low-risk PE patient in retrospective claims-based studies.
authors.affiliation: School of Pharmacy, University of Connecticut, 69 North Eagleville Road, Storrs, CT 06269 USA ; University of Connecticut/Hartford Hospital Evidence-Based Practice Center, Hartford, CT USA.
authors.forename: Erin R
authors.initials: ER
authors.lastname: Weeda
authors.affiliation: University of Saint Joseph School of Pharmacy, Hartford, CT USA ; University of Connecticut/Hartford Hospital Evidence-Based Practice Center, Hartford, CT USA.
authors.forename: Christine G
authors.initials: CG
authors.lastname: Kohn
authors.affiliation: Department of Emergency Medicine, University of Cincinnati, Cincinnati, OH USA.
authors.forename: Gregory J
authors.initials: GJ
authors.lastname: Fermann
authors.affiliation: Department of Emergency Medicine, Baylor College of Medicine, Houston, TX USA.
authors.forename: W Frank
authors.initials: WF
authors.lastname: Peacock
authors.affiliation: University of Saint Joseph School of Pharmacy, Hartford, CT USA.
authors.forename: Christopher
authors.initials: C
authors.lastname: Tanner
authors.affiliation: University of Saint Joseph School of Pharmacy, Hartford, CT USA.
authors.forename: Daniel
authors.initials: D
authors.lastname: McGrath
authors.affiliation: Janssen Scientific Affairs LLC, Raritan, NJ USA.
authors.forename: Concetta
authors.initials: C
authors.lastname: Crivera
authors.affiliation: Janssen Scientific Affairs LLC, Raritan, NJ USA.
authors.forename: Jeff R
authors.initials: JR
authors.lastname: Schein
authors.affiliation: School of Pharmacy, University of Connecticut, 69 North Eagleville Road, Storrs, CT 06269 USA ; University of Connecticut/Hartford Hospital Evidence-Based Practice Center, Hartford, CT USA.
authors.forename: Craig I
authors.initials: CI
authors.lastname: Coleman
keywords: Mortality; Prognosis; Pulmonary embolism; Risk assessment; Severity of illness index