Appropriateness of diagnostic management and outcomes of suspected pulmonary embolism

Ann Intern Med. 2006 Feb 7;144(3):157-64. doi: 10.7326/0003-4819-144-3-200602070-00003.


Background: International guidelines include several strategies for diagnosing pulmonary embolism with confidence, but little is known about how these guidelines are implemented in routine practice.

Objective: To evaluate the appropriateness of diagnostic management of suspected pulmonary embolism and the relationship between diagnostic criteria and outcome.

Design: Prospective cohort study with a 3-month follow-up.

Setting: 116 emergency departments in France and 1 in Belgium.

Patients: 1529 consecutive outpatients with suspected pulmonary embolism.

Measurements: Appropriateness of diagnostic criteria according to international guidelines; incidence of thromboembolic events during follow-up.

Results: Diagnostic management was inappropriate in 662 (43%) patients: 36 of 429 (8%) patients with confirmed pulmonary embolism and 626 of 1100 (57%) patients in whom pulmonary embolism was ruled out. Independent risk factors for inappropriate management were age older than 75 years (adjusted odds ratio, 2.27 [95% CI, 1.48 to 3.47]), known heart failure (odds ratio, 1.53 [CI, 1.11 to 2.12]), chronic lung disease (odds ratio, 1.39 [CI, 1.00 to 1.94]), current or recent pregnancy (odds ratio, 5.92 [CI, 1.81 to 19.30]), currently receiving anticoagulant treatment (odds ratio, 4.57 [CI, 2.51 to 8.31]), and the lack of a written diagnostic algorithm and clinical probability scoring in the emergency department (odds ratio, 2.54 [CI, 1.51 to 4.28]). Among patients who did not receive anticoagulant treatment, 44 had a thromboembolic event during follow-up: 5 of 418 (1.2%) patients who received appropriate management and 39 of 506 (7.7%) patients who received inappropriate management (absolute risk difference, 6.5 percentage points [CI, 4.0 to 9.1 percentage points]; P < 0.001). Inappropriateness was independently associated with thromboembolism occurrence (adjusted odds ratio, 4.29 [CI, 1.45 to 12.70]).

Limitations: This was an observational study without evaluation of the risk for overdiagnosis.

Conclusions: Diagnostic management that does not adhere to guidelines is frequent and harmful in patients with suspected pulmonary embolism. Several risk factors for inappropriateness constitute useful findings for subsequent interventions.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Belgium
  • Emergency Service, Hospital / standards*
  • Female
  • Follow-Up Studies
  • France
  • Guideline Adherence*
  • Humans
  • Male
  • Middle Aged
  • Outcome Assessment, Health Care*
  • Practice Guidelines as Topic*
  • Prospective Studies
  • Pulmonary Embolism / diagnosis*
  • Recurrence
  • Risk Factors