Clinical study
Comparison of two clinical prediction rules and implicit assessment among patients with suspected pulmonary embolism

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Abstract

Purpose

Two prediction rules for pulmonary embolism have been described recently: the Wells’ rule, which was derived from both outpatients and inpatients, and which includes a subjective element; and the Geneva rule, which is entirely standardized and is suitable only for emergency department patients. We compared the predictive accuracy and the concordance of the two methods, as well as the Geneva score overridden by implicit clinical judgment.

Subjects and methods

We studied 277 consecutive patients admitted to the emergency departments of three teaching hospitals. Clinical probability was assessed prospectively with the Geneva score and the Geneva score overridden by implicit clinical judgment in case of a disagreement. The Wells’ score was calculated retrospectively.

Results

The three methods classified similar proportions of patients as having a low (53% to 58% of patients), intermediate (37% to 41% of patients), or high (4% to 10% of patients) probability of pulmonary embolism. The actual frequencies of pulmonary embolism in each category were also similar (5% to 13% in the low, 38% to 40% in the intermediate, and 67% to 91% in the high clinical probability categories). Receiver operating characteristic curve analysis showed no difference between the two prediction rules, but the Geneva score overridden by implicit evaluation had a marginally higher accuracy. Concordance between the two prediction rules was fair (κ coefficient = 0.43). Clinicians disagreed with the Geneva score in 21% of patients (n = 57).

Conclusion

The two prediction rules had a similar predictive accuracy for pulmonary embolism among emergency department patients. The Geneva rule appears to be more accurate when combined with clinical judgment, although it does not apply to inpatients.

Section snippets

Patients

Consecutive patients admitted to the emergency departments of three teaching hospitals in Geneva and Lausanne, Switzerland, and Angers, France, for suspected pulmonary embolism were included in a prospective study of a diagnostic algorithm that included helical computed tomography (CT). We studied the first 390 patients enrolled in that study (from October 31, 2000, to April 1, 2001): 200 (51%) were from Geneva, 107 (27%) were from Lausanne, and 83 (21%) were from Angers. We excluded 113

Results

Most patients presented with chest pain or dyspnea (Table 2). Nine patients died during the 3-month follow-up; none from pulmonary embolism. Pulmonary embolism was diagnosed in 71 patients (26%) according to the study criteria (Table 3). Among the patients initially classified as not having pulmonary embolism, 2 were re-evaluated during the follow-up because of symptoms of venous thromboembolism. A deep vein thrombosis was confirmed in 1 patient by a positive ultrasonography, and a pulmonary

Discussion

We found that two recently published prediction rules for pulmonary embolism 13, 14 performed equally well in a sample of consecutive emergency department patients from three teaching hospitals. Furthermore, our results suggest that the Geneva rule performs better when complemented with implicit clinical judgment. The accuracy of the prediction rules was equivalent, but not superior, to that of implicit clinical judgment in the landmark PIOPED study (8) and several other series 9, 10.

This

Acknowledgements

We are indebted to all the internal medicine residents rotating in the emergency department for their help throughout the study and to Dominique Gillis, MD, for her help in collecting the data in Lausanne.

References (18)

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This study was supported by grant 00/4-T9 from the Royal College of Physicians and Surgeons, Canada; a grant from La Fondation Québécoise pour le Progrès de la Médecine Interne and Les Internistes et Rhumatologues Associés de l’Hôpital du Sacré-Cœur, Montréal, Canada; and grant 32-61773.00 from the Swiss National Science Foundation, Bern, Switzerland.

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