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This issue of Annals includes two articles about the management of pulmonary embolism (PE).
One reports on decisions to confirm or rule out PE in 1,529 consecutive patients who went to 117 emergency departments with suspected PE (Article, p. 157). Researchers found that emergency departments failed to use the recommended evaluation procedures in 662 of the 1,529 patients. Departments followed established guidelines to confirm PE much more often than they followed guidelines for ruling out PE. In the following three months, PE, deep vein thrombosis or death was markedly lower among patients who received appropriate diagnostic management (1.2 percent) than among those who did not (7.7 percent).
The other article describes development of a new clinical prediction rule for estimating the probability of PE (Article, p. 165). The new rule is standardized, based on clinical variables and is independent of physicians' implicit judgments. It also identifies people at low risk (less than 10 percent) of developing PE or high risk (more than 60 percent), which can indicate the need for tests to confirm clinical suspicion of PE. The new rule uses criteria such as age, previous deep venous thrombosis or PE, surgery or fracture within the prior month, or an active malignant condition. The authors say the new "revised Geneva score" for PE is "clinically relevant, is easy to compute, and has sustained internal and external validation. It should now be tested for clinical usefulness in a formal outcome study."
An editorial writer says that the first article shows that physicians and emergency departments follow accepted guidelines for ruling in PE much better than they follow guidelines for ruling out likelihood PE, resulting in bad patient outcomes (Editorial, p. 210). The second study provides a new, simple predictive rule for PE, which will help doctors to classify patients and to choose the right tests. The goal, says the writer, is to get existing "tools for diagnosis of PE used consistently in day-to-day clinical practice." To do this, he envisions the physician "entering the findings specified by a clinical prediction rule, perhaps at the bedside by using a hand-held computer." The computer could then specify "a patient-specific diagnosis and management algorithm" suitable to the patient's probability of having PE.