Journal Club

Comparison 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 Ddimer) 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

BASELINE CHARECTERISTICS

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? Is the person who measures the outcome blinded?

YES

Yes

NO

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 its result applicable to your own patient population?
Yes?