Implementation, Clinical Benefit and Safety of a D-Dimer-Focused Pulmonary Embolism Testing Pathway in the Emergency Department - 24/04/24

Doi : 10.1016/j.annemergmed.2024.03.010

Federico Germini, MD ^a,^b, Fayad Al-Haimus, MBChB ^c, Yang Hu, BSc ^b, Shawn Mondoux, MD ^b,^d, Quazi Ibrahim, MSc ^a, Noel Chan, MD ^b, Rick Ikesaka, MD ^b, Joshua Klyn, BSc ^b, Natasha Clayton, CRA ^b, Lehana Thabane, PhD ^a,^b,^e,^f,^g,^h,ⁱ, Kerstin de Wit, MBChB ^a,^j,^⁎
^a Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
^b Department of Medicine, McMaster University, Hamilton, ON, Canada
^c Division of Emergency Medicine, Department of Medicine, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
^d Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
^e Schools of Nursing and Rehabilitation Sciences, McMaster University, Hamilton, ON, Canada
^f Departments of Surgery and Family Medicine, McMaster University, Hamilton, ON, Canada
^g Biostatistics Unit, Father Sean O'Sullivan Research Centre, St Joseph's Healthcare, Hamilton, ON, Canada
^h Departments of Paediatrics and Anaesthesia, McMaster University, Hamilton, ON, Canada
ⁱ Faculty of Health Sciences, University of Johannesburg, Johannesburg, South Africa
^j Department of Emergency Medicine, Queen’s University, Kingston, ON, Canada

^∗Corresponding Author.

Sous presse. Épreuves corrigées par l'auteur. Disponible en ligne depuis le Wednesday 24 April 2024

Abstract

Study objective

Computed tomography pulmonary angiogram (CTPA) is overused during pulmonary embolism (PE) testing in the emergency department (ED), whereas prediction rules and D-dimer are underused. We report the adherence, clinical benefit, and safety of a D-dimer-only strategy to guide need for PE imaging in the ED.

Methods

This was a prospective multicenter implementation study in 2 EDs with historical and external controls. Patients with suspected PE underwent D-dimer testing and imaging (CTPA or ventilation-perfusion scan) when D-dimer levels were 500 ng/mL or more. PE was ruled out if D-dimer was less than 500 ng/mL or with negative imaging. The primary implementation outcome was the proportion of patients tested for PE in adherence with the pathway. The primary clinical benefit outcome was the proportion of patients tested for PE who received pulmonary imaging. The primary safety outcome was diagnosis of PE in the 30 days following negative PE testing postimplementation.

Results

Between January 2018 and June 2021, 16,155 patients were tested for PE, including 33.4% postimplementation, 30.7% preimplementation, and 35.9% in an external control site. Adherence with the D-dimer-only pathway was 97.6% (adjusted odds ratio (aOR) post- versus preimplementation 5.26 (95% confidence interval 1.70 to 16.26). There was no effect on the proportion undergoing PE imaging. Imaging yield increased aOR 4.89 (1.17 to 20.53). Two cases of PE (0.04%; 0.01% to 0.16%) were diagnosed within 30 days.

Conclusion

In this Canadian ED study, the uptake of a D-dimer-only PE testing strategy was high. Implementation was associated with higher imaging yield and a D-dimer level of less than 500 ng/mL safely excluded PE.

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Plan

Introduction

Background

Importance

Goals of This Investigation

Materials and Methods

Study Design and Setting

Selection of Participants

	Supervising editor: Allan B. Wolfson, MD. Specific detailed information about possible conflict of interest for individual editors is available at editors.
	Author contributions: KdW conceived the study and takes overall responsibility for the data. FG, KdW, and SM designed the intervention. N Clayton built the database and facilitated the data extraction. YH and FAH extracted the data. KdW, FG, N Clayton, YH, and FAH implemented the intervention. QI conducted the data analysis. LT contributed with expertise in health research methodology. FG and KdW drafted the manuscript. N Chan and RI adjudicated the study outcomes. All the authors read, edited, and approved the final manuscript. KdW takes responsibility for the paper as a whole.
	Data sharing statement: The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.
	All authors attest to meeting the four ICMJE.org authorship criteria: (1) Substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work; AND (2) Drafting the work or revising it critically for important intellectual content; AND (3) Final approval of the version to be published; AND (4) Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
	Funding and support: By Annals’ policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org/). This research was supported by a CanVECTOR research fellowship award (Federico Germini, Funding Reference: CDT-142654), a Hamilton Health Sciences Foundation Early Career Award (Kerstin de Wit) and Physicians’ Services Incorporation Graham Farquharson Knowledge Translation Fellowship award (Kerstin de Wit). The project received funding support from the McMaster Division of Hematology & Thromboembolism, the Society for the Improvement of Diagnosis in Medicine seed grant, and an educational Pfizer grant.
	Presentation information: These results were presented at the Canadian Association of Emergency Physicians Annual Conference in Québec City, Canada in June 2022.
	Please see page XX for the Editor’s Capsule Summary of this article.