Journal ClubComparison of the Unstructured Clinician Gestalt, the WellsScore, and the Revised Geneva Score to

Estimate Pretest Probability for Suspected Pulmonary Embolism

Introduction

• Background:• With an estimated annual incidence of 70 cases

per100,000 population,pulmonary embolism is a frequent,potentially life-threatening and difficult-to-diagnose condition.

• Most often a missed diagnosis. • The most accurate way to assess clinical

probability remains unknown.

Question

• Do treating physicians assess pulmonary embolism risk as accurately as 2 widely used clinical decision rules?

Study Design• Large multi-center diagnostic study• This study is based on the retrospective

analysis of a prospective cohort study• The study was conducted in 116 emergency departments (EDs) in France and 1 in Belgium

STUDY POPULATION

INCLUSION CRITERIA

• During a 5-week period, consecutive patients presenting to ED with clinical suspicion of pulmonary embolism and for whom any diagnostic testing for this suspicion was performed (including D-dimer) were included.

EXCLUSION CRITERIA• In whom the diagnosis of thromboembolic disease was

documented before admission• Pulmonary embolism was suspected among inpatients (hospital

stay of more than 2 days’ duration.• Diagnostic testing was cancelled for ethical reasons, because

of rapid death, or because the patient decided to leave the hospital against medical advice or declined testing.

CLINICAL DECISION RULES

Outcome Measures•What are the criteria used to measure the outcome?

The predetermined primary outcome measure was major cardiovascular events.Predetermined secondary outcome measures included•All – cause mortality•Any cardio vascular end-point•Median lipid level at base line

RESULTS

RESULTS

LIMITATIONS• First, it was a secondary retrospective analysis of a

prospective study, which was not designed or powered to compare clinical probability assessment methods.

• Second, clinical decision rules were retrospectively calculated.However, concerning the Wells score, the likelihood of an alternative diagnosis was prospectively assessed but not used in the diagnostic strategy, which could result in misevaluation.

LIMITATIONS

• Third, the overall prevalence in our study was high (31.3%),as classically described in European studies Application of these results to other emergency medicine practices, in particular in an area with low pulmonary embolism prevalence such as North America, could be questionable.

•Was the study point addressed? • Are the criteria objective and consistently applied?

Yes

•Is the person who measures the outcome blinded?

NO

YES

Study Factors

•Are they described in detail?Yes

•Are interventions feasible and available? Yes

•Are exposures measured objectively and consistently? Yes

Confounders•Do the investigators acknowledge potential confounders?

Yes

•Do they control adjust for them in the analysis?

Yes

Clinically Sufficient•Is the outcome an important one that you care about?

Yes

•Is the magnitude of the result clinically important?

Yes

Conclusion

•Are the authors conclusion reasonable based on the data and generalizable?

Yes

•Are the study and it’s result applicable to your own patient population?

Yes?