Tracking the Uptake of Evidence

Stein, Paul D.; Hull, Russell D.; Ghali, William A.; Patel, Kalpesh C.; Olson, R. E.; Meyers, Frederick A.; Kalra, Neeraj

doi:10.1001/archinte.163.10.1213

Cited by 65 publications

(6 citation statements)

References 82 publications

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“…Non adherence to these recommendations and ordering excessive CTPA in a clinical setting exposes the patients to several risks of which overdiagnosis and/or overtreatment is the most serious ( 5 ). VQ scanning was introduced in the mid-1960s as the first diagnostic imaging modality for pulmonary embolism ( 6 ). Nevertheless, its main disadvantage was inconclusive results.…”

Section: Discussionmentioning

confidence: 99%

Computed Tomography Pulmonary Angiography for Evaluation of Patients with Suspected Pulmonary Embolism: Use or Overuse

et al. 2015

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Background:The use of computed tomography pulmonary angiography (CTPA) has been increased during the last decade.Objectives:We studied the adherence to current diagnostic recommendations for evaluation of pulmonary embolism in a teaching hospital of Tehran University of Medical Sciences.Patients and Methods:The registered medical records (Wells scores and serum D-dimer level) of all patients whose CTPA was performed with suspicion of pulmonary thromboembolism (PTE) were studied retrospectively. Modified Wells score of each patient was determined without being aware of the CTPA results. The patients were categorized to those with a high (likely) clinical probability (score > 4) and low (unlikely) clinical probability (score≤ 4) of PTE.Results:During a 6-month period, 82 patients who underwent CTPA were included. The prevalence of PTE was 62.2% in the group of subjects with a likely clinical risk. In 45 (54.8%) of those patients whose CTPA was requested, the PTE was unlikely based on modified Wells criteria. In the clinically unlikely group, serum D-dimer assay was done in 15 out of 45 (33.3%), while it was inappropriately checked in 10 out of 37 (27.0%) with a clinically likely risk. General adherence rate to diagnostic algorithm of PTE was 43.9%.Conclusion:There is still excessive unjustified concern of PTE in less trained physicians leading to excessive diagnostic work-up. Loyalty to the existing guideline for management of suspected PTE in educational hospitals and supervision of attending physicians could prevent overuse of CTPA.

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Section: Discussionmentioning

confidence: 99%

Computed Tomography Pulmonary Angiography for Evaluation of Patients with Suspected Pulmonary Embolism: Use or Overuse

et al. 2015

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“…The clinician can only benefit from reports, which clearly express the presence or absence of PE. This goal was not reached with previous probabilistic reporting methods according to PIOPED or modified PIOPED, which defied how planar scans are reported [1, 31]. Large V/P SPECT studies show that this is achievable if all patterns representing ventilation together with perfusion are considered [23, 32–34].…”

Section: Interpretation With Emphasis On Pementioning

confidence: 99%

Ventilation/Perfusion SPECT for Diagnosis of Pulmonary Embolism and Other Diseases

Bajc

Jonson

2011

International Journal of Molecular Imaging

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V/PSPECT has the potential to become a first hand tool for diagnosis of pulmonary embolism based on standardized technology and new holistic interpretation criteria. Pretest probability helps clinicians choose the most appropriate objective test for diagnosis or exclusion of PE. Interpretation should also take into account all ventilation and perfusion patterns allowing diagnosis of other cardiopulmonary diseases than PE. In such contexts, V/PSPECT has excellent sensitivity and specificity. Nondiagnostic reports are ≤3%. V/PSPECT has no contraindication; it is noninvasive and has very low radiation exposure. Moreover, acquisition time for V/PSPECT is only 20 minutes. It allows quantification of PE extension which has an impact on individual treatment. It is uniquely useful for followup and research.

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“…Contrast venography is accepted as the gold standard for the detection of DVT; however, this technique has its own disadvantages due to extravasation of the contrast medium, systemic reactions to the contrast medium and venous thrombosis at the catheter site. [3,4] Ultrasound (US) is widely recognized as a choice of the imaging methods for suspected DVT thanks to its noninvasiveness, low cost, ready availability, portability, safety, and operator-friendliness. [5] The McMaster Diagnostic Imaging Practice Guidelines Initiative reported that US had a sensitivity of 97% for proximal DVT and 73% for distal DVT, and a specificity of 96%.…”

Section: Introductionmentioning

confidence: 99%

The rate of missed diagnosis of lower-limb DVT by ultrasound amounts to 50% or so in patients without symptoms of DVT

Zhang¹,

Xia²,

Wang

et al. 2019

Medicine

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Background:To assess whether the ultrasound (US) is a reliable approach in detecting lower-limb deep-vein thrombosis (DVT) in patients without symptoms of DVT.Methods:The research team performed a systematic search in PubMed, Ovid, Cochrane, and Web of Science without language or date restrictions. Full-text reports on prospective diagnostic studies involve the detection of lower-limb proximal and distal DVT in patients without symptoms of DVT using US and venography. A meta-analysis was performed using Meta-DiSc (version 1.4), providing the pooled sensitivity, specificity, positive (LR+) and negative (LR–) likelihood ratios of the detection accuracy of US. There were 4 different classes of subgroup analysis—the class of patients stratified by location of US exam (proximal, distal, whole leg), the class stratified by technique (color/doppler, compression, both modalities), the class stratified by kind of surgery (orthopedic, otherwise hospitalized) and the class stratified by era of publishing (1980s, 1990s, 2000s). The study quality and the risk of bias were evaluated using QUADAS-2, with heterogeneity was assessed and quantified by the Q score and I2 statistics, respectively.Results:The meta-analysis included 26 articles containing 41 individual studies with a total of 3951 patients without symptoms of DVT. Using venography as the gold standard, US for proximal DVT had a pooled sensitivity of 59% (95% confidence interval (CI) = 51%–66%) and a pooled specificity of 98% (95% CI = 97%–98%), US for distal DVT had a poor sensitivity of 43% (95% CI = 38%–48%) and a pooled specificity of 95% (95% CI = 94%–96%), US for whole-leg DVT had a pooled sensitivity of 59% (95% CI = 54%–64%) and a pooled specificity of 95% (95% CI = 94%–96%), US for post-major orthopedic surgery patients had a pooled sensitivity of 52% (95% CI = 49%–55%), and US for other types of patients had a pooled sensitivity of 58% (95% CI = 43%–72%). Pure compression technique for DVT had a poor sensitivity of 43% (95% CI = 39%–48%), pure color/doppler technique for DVT had a pooled sensitivity of 58% (95% CI = 53%–63%), compression and color/doppler technique for DVT had a pooled sensitivity of 61% (95% CI = 48%–74%).Conclusion:US could be a useful tool for diagnosing DVT, but it has a lower positive rate and a higher false negative rate. The rate of missed diagnosis of lower-limb DVT by US amounts to 50% or so in the patients without symptoms of DVT. The negative results do not preclude the possibility of DVT and if appropriate heightened surveillance and continued monitoring or try a more accurate inspection method is warranted. The whole leg evaluation and color/doppler technique should be the preferred approach.

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Tracking the Uptake of Evidence

Cited by 65 publications

References 82 publications

Computed Tomography Pulmonary Angiography for Evaluation of Patients with Suspected Pulmonary Embolism: Use or Overuse

Computed Tomography Pulmonary Angiography for Evaluation of Patients with Suspected Pulmonary Embolism: Use or Overuse

Ventilation/Perfusion SPECT for Diagnosis of Pulmonary Embolism and Other Diseases

The rate of missed diagnosis of lower-limb DVT by ultrasound amounts to 50% or so in patients without symptoms of DVT

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