OBJECTIVE: To determine whether decision analysis is applicable to routine management of suspected pulmonary embolism in an emergency care setting. DESIGN: Controlled feasibility trial. SETTING: Emergency center of a university hospital. PATIENTS: Outpatients (n = 84) admitted with clinical and scintigraphic evidence of pulmonary embolism. INTERVENTIONS: Patients were treated either with the usual clinical work-up for pulmonary embolism (control group) or using a decision analysis model with three options: no action: angiography followed by treatment if positive; treatment without angiography. RESULTS: All six senior residents in the decision analysis group agreed to fully participate for the 16 months of the study. Summarizing the decision analysis model in a graph was critical to obtain acceptance from all the physicians. Decision analysis (n = 43) and control (n = 41) patients underwent similar numbers of angiographies. However, angiographies for patients who had intermediate clinical probabilities of pulmonary embolism, between 25 and 75%, were more frequent in the decision analysis group (9/13 = 69%) than in the control group (7/20 = 35%). Agreement between clinical probability and lung-scan result was stronger in the decision analysis group. CONCLUSIONS: Decision analysis was successfully used to manage all patients suspected of having pulmonary embolism admitted to an emergency center during the 16-month trial. There was no insuperable obstacle to acceptance of clinical decision analysis by the physicians. Decision analysis may have resulted in a better discrimination between low and intermediate clinical probabilities of pulmonary embolism.
OBJECTIVE: To determine whether decision analysis is applicable to routine management of suspected pulmonary embolism in an emergency care setting. DESIGN: Controlled feasibility trial. SETTING: Emergency center of a university hospital. PATIENTS: Outpatients (n = 84) admitted with clinical and scintigraphic evidence of pulmonary embolism. INTERVENTIONS:Patients were treated either with the usual clinical work-up for pulmonary embolism (control group) or using a decision analysis model with three options: no action: angiography followed by treatment if positive; treatment without angiography. RESULTS: All six senior residents in the decision analysis group agreed to fully participate for the 16 months of the study. Summarizing the decision analysis model in a graph was critical to obtain acceptance from all the physicians. Decision analysis (n = 43) and control (n = 41) patients underwent similar numbers of angiographies. However, angiographies for patients who had intermediate clinical probabilities of pulmonary embolism, between 25 and 75%, were more frequent in the decision analysis group (9/13 = 69%) than in the control group (7/20 = 35%). Agreement between clinical probability and lung-scan result was stronger in the decision analysis group. CONCLUSIONS: Decision analysis was successfully used to manage all patients suspected of having pulmonary embolism admitted to an emergency center during the 16-month trial. There was no insuperable obstacle to acceptance of clinical decision analysis by the physicians. Decision analysis may have resulted in a better discrimination between low and intermediate clinical probabilities of pulmonary embolism.
Authors: R D Hull; J Hirsh; C J Carter; G E Raskob; G J Gill; R M Jay; J R Leclerc; M David; G Coates Journal: Chest Date: 1985-12 Impact factor: 9.410