Multicenter Evaluation of the
            <scp>YEARS</scp>
            Criteria in Emergency Department Patients Evaluated for Pulmonary Embolism

Kabrhel, Christopher; Vlieg, Astrid van Hylckama; Muzikanski, Alona; Singer, Adam J.; Fermann, Gregory J.; Francis, Samuel; Limkakeng, Alexander T.; Chang, Ann Marie; Giordano, N.; Parry, Blair A.

doi:10.1111/acem.13417

Cited by 45 publications

(37 citation statements)

References 25 publications

Supporting

Mentioning

Contrasting

Order By: Relevance

“…Kline et al 8 (2012) retrospectively reviewed 678 patients, with a PE rate of 19%, doubled-traditional threshold was found to be 90.6% sensitive. Similarly, with the newly proposed YEARS criteria in our cohort we found a lower sensitivity than what was originally reported by Van Der Hulle et al 9 (96.2%) and a validation study in the USA by Kabrhel et al 12 (92.9%). Using the YEARS criteria in our cohort would have resulted in nine missed PE, of which four were segmental or greater.…”

Section: Discussionsupporting

confidence: 63%

“…Similarly, with the newly proposed YEARS criteria in our cohort we found a lower sensitivity than what was originally reported by Van Der Hulle et al . (96.2%) and a validation study in the USA by Kabrhel et al . (92.9%).…”

Section: Discussionsupporting

confidence: 58%

“…While clinician and patient acceptance of risk will vary it has been suggested that at 2% probability of PE, the risk of testing to the patient, risk of major bleeding from anticoagulation, mortality from contrast-induced renal failure and risk of cancer from computed tomography scan, may outweigh the benefits. 12,14 Applying any of the CDR studied in this cohort of low-risk patients would have resulted in a post-test rate of PE of less than 2%. However, YEARS and doubled-threshold D-dimer both had sensitivities of below 90%, which may not be acceptable to some clinicians.…”

Section: Discussionmentioning

confidence: 97%

See 2 more Smart Citations

Comparison of Wells and YEARS clinical decision rules with D‐dimer for low‐risk pulmonary embolus patients

McLenachan

Chua

Chan

et al. 2019

Internal Medicine Journal

View full text Add to dashboard Cite

Background Assessment of pulmonary embolism (PE) remains a diagnostic and investigative burden to emergency departments. The decision of which D‐dimer cut‐off to use in low‐risk patients remains controversial. Aims To compare the sensitivity and specificity of varying D‐dimer cut‐offs in the diagnosis of PE for Wells low‐risk patients. Methods Retrospective review of patients presenting to a tertiary emergency department over 42 months who had a D‐dimer performed for PE risk stratification. Wells scores were calculated for each patient, those with Wells score of ≤4 (‘PE unlikely’) were analysed. Four D‐dimer thresholds were compared, including traditional threshold (≥0.5 μg/mL), age‐adjusted (≥age in years × 0.01 μg/mL), doubled‐traditional threshold and YEARS criteria. Results During the study period, 2291 D‐dimers were ordered for suspected PE, of which 2125 were low risk for PE. Of these low‐risk patients 46 (2.2%) were found to have a PE. The sensitivity and specificity for each D‐dimer threshold were traditional threshold (95.6% and 65.6%), age‐adjusted (93.5% and 71.7%), doubled traditional (69.6% and 85.5%) and YEARS criteria (80.4% and 84.0%). Utilising an age‐adjusted threshold, YEARS criteria or doubled‐traditional threshold would have resulted in 70, 217 and 245 fewer imaging investigations. Conclusions The prevalence of PE in this low‐risk cohort was very low. Utilising an age‐adjusted D‐dimer would have reduced imaging tests performed while maintaining good sensitivity. Although The YEARS criteria and doubled‐traditional threshold would have reduced scanning considerably both had sensitivities of less than 90%.

show abstract

Section: Discussionsupporting

confidence: 63%

Section: Discussionsupporting

confidence: 58%

Section: Discussionmentioning

confidence: 97%

See 1 more Smart Citation

Comparison of Wells and YEARS clinical decision rules with D‐dimer for low‐risk pulmonary embolus patients

McLenachan

Chua

Chan

et al. 2019

Internal Medicine Journal

View full text Add to dashboard Cite

show abstract

“…15 Finally, the safety of applying a d-dimer threshold on the basis of pretest probability of pulmonary embolism has been shown in other international studies. 25,26 In addition, the YEARS algorithm has been shown to be associated with a reduction in the detection of potentially clinically irrelevant subsegmental pulmonary embolism and with both a shorter visit time and reduced costs in the emergency department. 27,28 Strengths of our study include the prospective design, large sample size, and near complete follow-up.…”

Section: Discussionmentioning

confidence: 99%

Pregnancy-Adapted YEARS Algorithm for Diagnosis of Suspected Pulmonary Embolism

Pol

Tromeur

Bistervels

et al. 2019

Obstetrical &Amp; Gynecological Survey

View full text Add to dashboard Cite

BACKGROUNDPulmonary embolism is one of the leading causes of maternal death in the Western world. Because of the low specificity and sensitivity of the d-dimer test, all pregnant women with suspected pulmonary embolism undergo computed tomographic (CT) pulmonary angiography or ventilation-perfusion scanning, both of which involve radiation exposure to the mother and fetus. Whether a pregnancy-adapted algorithm could be used to safely avoid diagnostic imaging in pregnant women with suspected pulmonary embolism is unknown. METHODSIn a prospective study involving pregnant women with suspected pulmonary embolism, we assessed three criteria from the YEARS algorithm (clinical signs of deep-vein thrombosis, hemoptysis, and pulmonary embolism as the most likely diagnosis) and measured the d-dimer level. Pulmonary embolism was ruled out if none of the three criteria were met and the d-dimer level was less than 1000 ng per milliliter or if one or more of the three criteria were met and the d-dimer level was less than 500 ng per milliliter. Adaptation of the YEARS algorithm for pregnant women involved compression ultrasonography for women with symptoms of deep-vein thrombosis; if the results were positive (i.e., a clot was present), CT pulmonary angiography was not performed. All patients in whom pulmonary embolism had not been ruled out underwent CT pulmonary angiography. The primary outcome was the incidence of venous thromboembolism at 3 months. The secondary outcome was the proportion of patients in whom CT pulmonary angiography was not indicated to safely rule out pulmonary embolism. RESULTSA total of 510 women were screened, of whom 12 (2.4%) were excluded. Pulmonary embolism was diagnosed in 20 patients (4.0%) at baseline. During follow-up, popliteal deep-vein thrombosis was diagnosed in 1 patient (0.21%; 95% confidence interval [CI], 0.04 to 1.2); no patient had pulmonary embolism. CT pulmonary angiography was not indicated, and thus was avoided, in 195 patients (39%; 95% CI, 35 to 44). The efficiency of the algorithm was highest during the first trimester of pregnancy and lowest during the third trimester; CT pulmonary angiography was avoided in 65% of patients who began the study in the first trimester and in 32% who began the study in the third trimester. CONCLUSIONSPulmonary embolism was safely ruled out by the pregnancy-adapted YEARS diagnostic algorithm across all trimesters of pregnancy. CT pulmonary angiography was avoided in 32 to 65% of patients. (Funded by Leiden University Medical Center and 17 other participating hospitals; Artemis Netherlands Trial Register number, NL5726.)

show abstract

“…Yet, fewer than 10% of these scans show PE . Multiple validated risk stratification tools exist to promote appropriate workup for PE and are recommended by professional society guidelines, including the Pulmonary Embolism Rule Out Criteria (PERC), Wells score, and D‐dimer laboratory test (Figure ) . Provider uptake of the tools has been slow, with recent ED studies finding 25% of patients who warranted no laboratory or imaging studies still received testing .…”

Section: Introductionmentioning

confidence: 99%

Provider Perspectives on the Use of Evidence‐based Risk Stratification Tools in the Evaluation of Pulmonary Embolism: A Qualitative Study

Westafer

Kunz

Bugajska

et al. 2020

Academic Emergency Medicine

View full text Add to dashboard Cite

Objectives Providers often pursue imaging in patients at low risk of pulmonary embolism (PE), resulting in imaging yields <10% and false‐positive imaging rates of 10% to 25%. Attempts to curb overtesting have had only modest success and no interventions have used implementation science frameworks. The objective of this study was to identify barriers and facilitators to the adoption of evidence‐based diagnostic testing for PE. Methods We conducted semistructured interviews with a purposeful sample of providers. An interview guide was developed using the implementation science frameworks, consolidated framework for implementation research, and theoretical domains framework. Interviews were recorded, transcribed, and analyzed in an iterative process. Emergent themes were identified, discussed, and organized. Results We interviewed 23 providers from four hospital systems, and participants were diverse with regard to years in practice and practice setting. Barriers were predominately at the provider level and included lack of knowledge of the tools, particularly misunderstanding of the validated scoring systems in Wells, as well as risk avoidance and need for certainty. Barriers to prior implementation strategies included the perception of a clinical decision support (CDS) tool for PE as adding steps with little value; most participants reported that they overrode CDS interventions because they had already made the decision. All providers identified institution‐level strategies as facilitators to use, including endorsed guidelines, audit feedback with peer comparison about imaging yield, and peer pressure. Conclusions This exploration of the use of risk stratification tools in the evaluation of PE found that barriers to use primarily exist at the provider level, whereas facilitators to the use of these tools are largely perceived at the level of the institution. Future efforts to promote the evidence‐based diagnosis of PE should be informed by these determinants.

show abstract

Multicenter Evaluation of the YEARS Criteria in Emergency Department Patients Evaluated for Pulmonary Embolism

Abstract: D-dimer adjustment based on PTP may result in a reduced need for imaging to evaluate possible PE, with some additional missed PE but no decrease in NPV.

Cited by 45 publications

References 25 publications

Comparison of Wells and YEARS clinical decision rules with D‐dimer for low‐risk pulmonary embolus patients

Comparison of Wells and YEARS clinical decision rules with D‐dimer for low‐risk pulmonary embolus patients

Pregnancy-Adapted YEARS Algorithm for Diagnosis of Suspected Pulmonary Embolism

Provider Perspectives on the Use of Evidence‐based Risk Stratification Tools in the Evaluation of Pulmonary Embolism: A Qualitative Study

Contact Info

Product

Resources

About