A pilot study to assess feasibility of evaluating the safety and efficiency of a simplified diagnostic approach for pulmonary embolism
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Authors
Morris, Nicole Faith
Date
2024-05-23
Type
thesis
Language
eng
Keyword
pulmonary embolism , emergency department , decision rule
Alternative Title
Abstract
Background: Decision rules designed to reduce the need for pulmonary embolism (PE) imaging are seldom used by emergency physicians because of their complexity and poor credibility. We designed a simple, modified age-adjusted decision rule for PE testing in the emergency department (ED) – the ‘Adjust-Unlikely’ rule. Given increasing pressure on EDs, alternative methods to in-person recruitment are needed to validate the diagnostic performance of the Adjust-Unlikely rule in a full-scale study.
Objectives: The primary objective of this research was to assess the feasibility of a protocol consenting patients tested for suspected PE with the Adjust-Unlikely rule by telephone after they left the ED. The secondary objectives were to estimate safety and efficiency of the Adjust-Unlikely rule for diagnosing PE in the ED and to assess whether our methods introduced spectrum bias.
Methods: A prospective management pilot study was conducted in one ED and one urgent care centre. Adult patients tested for PE using the Adjust-Unlikely rule were recruited by telephone and followed for 90 days to identify subsequent testing for venous thromboembolism. PE and deep vein thrombosis (DVT) testing during follow-up was independently adjudicated. The feasibility outcomes were recruitment rate, missed eligible rate and overall follow-up rate. To assess for spectrum bias, multivariable logistic regression was used to compare included patients to missed eligible patients and patients who declined participation.
Results: Two hundred patients were included. On average, 9 patients were recruited per site, per week and 6 patients were missed per site, per week. The overall follow-up rate was 96.5%. Of the 143 patients with a negative Adjust-Unlikely rule on index visit, 1 patient was diagnosed with PE during follow-up. We found evidence of spectrum bias in our study population. Female patients and older patients were over-represented in our study population compared to patients who were eligible but not included.
Conclusions: Telephone recruitment did not meet our predefined thresholds for feasibility. This research has informed the design and planning of a full-scale study that will prospectively validate the safety and efficiency of the Adjust-Unlikely rule for diagnosing PE in the ED across Ontario.
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Attribution-NonCommercial-NoDerivatives 4.0 International
ProQuest PhD and Master's Theses International Dissemination Agreement
Intellectual Property Guidelines at Queen's University
Copying and Preserving Your Thesis
This publication is made available by the authority of the copyright owner solely for the purpose of private study and research and may not be copied or reproduced except as permitted by the copyright laws without written authority from the copyright owner.
Attribution-NonCommercial-NoDerivatives 4.0 International