Diagnostic prediction models for suspected pulmonary embolism: systematic review and independent external validation in primary care

Abstract

ObjeCtiveTo validate all diagnostic prediction models for ruling out pulmonary embolism that are easily applicable in primary care. DesignSystematic review followed by independent external validation study to assess transportability of retrieved models to primary care medicine. setting 300 general practices in the Netherlands. PartiCiPantsIndividual patient dataset of 598 patients with suspected acute pulmonary embolism in primary care. Main OutCOMe MeasuresDiscriminative ability of all models retrieved by systematic literature search, assessed by calculation and comparison of C statistics. After stratification into groups with high and low probability of pulmonary embolism according to pre-specified model cut-offs combined with qualitative D-dimer test, sensitivity, specificity, efficiency (overall proportion of patients with low probability of pulmonary embolism), and failure rate (proportion of pulmonary embolism cases in group of patients with low probability) were calculated for all models. results Ten published prediction models for the diagnosis of pulmonary embolism were found. Five of these models could be validated in the primary care dataset: the original Wells, modified Wells, simplified Wells, revised Geneva, and simplified revised Geneva models. Discriminative ability was comparable for all models (range of C statistic 0.75-0.80). Sensitivity ranged from 88% (simplified revised Geneva) to 96% (simplified Wells) and specificity from 48% (revised Geneva) to 53% (simplified revised Geneva). Efficiency of all models was between 43% and 48%. Differences were observed between failure rates, especially between the simplified Wells and the simplified revised Geneva models (failure rates 1.2% (95% confidence interval 0.2% to 3.3%) and 3.1% (1.4% to 5.9%), respectively; absolute difference −1.98% (−3.33% to −0.74%)). Irrespective of the diagnostic prediction model used, three patients were incorrectly classified as having low probability of pulmonary embolism; pulmonary embolism was diagnosed only after referral to secondary care. COnClusiOnsFive diagnostic pulmonary embolism prediction models that are easily applicable in primary care were validated in this setting. Whereas efficiency was comparable for all rules, the Wells rules gave the best performance in terms of lower failure rates.

Increasing rate of pulmonary embolism diagnosed in hospitalized children in the United States from 2001 to 2014

“…[9][10][11] However, these have not been validated in children, and when these have been applied to a pediatric population, they do not perform as well, and those typically used clinical findings such as the D-dimer have been nondiscriminatory. 12,13 A case-control study investigating risk factors and clinical features that distinguished children with PE from those without identified current or recent use of the oral contraceptive pill as the most significant risk factor.…”

Pulmonary embolism occuring in the patient who treated by spinal cord stimulation

“…This causes the diagnosis of pulmonary embolism to be easily missed. [6] Our patients had no other symptoms except slight chest pain, slight cough, and fatigue. It helped us think that the patient was immobile.…”

“…[4] Pulmonary embolism is a potentially fatal condition if left untreated. [6,7] Its presentation can be relatively mild, sometimes even mimicking myalgia or a simple cough. This causes the diagnosis of pulmonary embolism to be easily missed.…”

Ūminė Plaučių Arterijos Trombinė Embolija: Wells Ir Modifikuotos Geneva Skalių Bei D-Dimerų Koncentracijos Prognostinės Vertės Senyvo Amžiaus Pacientams

“…Modifikuota Geneva skalė paremta vien objektyviais klinikiniais kriterijais, todėl klinicisto subjektyvumas ir turima klinikinė patirtis neturi įtakos paciento įvertinimui (22). Manyta, kad PATE tikėtinumo nustatymas remiantis modifikuota Geneva skale yra objektyvesnis nei remiantis Wells skale (22), tačiau studijos, lyginusios šias skales tarpusavyje, Wells skalę nustatė esant jautresnę ir specifiškesnę nei modifikuota Geneva skalė (11,(23)(24)(25). Nedaug studijų lygino šių skalių prognostinę vertę diagnozuojant PATE senyvo amžiaus pacientams (23).…”