Application of an evidence-based decision rule to patients with suspected pulmonary embolism
Article first published online: 28 DEC 2012
© 2012 John Wiley & Sons Ltd
Journal of Evaluation in Clinical Practice
Special Issue: EBM Thematic Issue
Volume 19, Issue 4, pages 682–688, August 2013
How to Cite
Zwaan, L., Thijs, A., Wagner, C. and Timmermans, D. R. M. (2013), Application of an evidence-based decision rule to patients with suspected pulmonary embolism. Journal of Evaluation in Clinical Practice, 19: 682–688. doi: 10.1111/jep.12019
- Issue published online: 28 JUL 2013
- Article first published online: 28 DEC 2012
- Manuscript Accepted: 8 NOV 2012
- Dutch Ministry of Health, Welfare and Sport
- clinical decision rules;
- evidence-based medicine;
- medical-decision making;
- pulmonary embolism
To support doctors in diagnosing patients who are suspected to have pulmonary embolism, the Christopher evidence-based decision rule was implemented in hospitals in the Netherlands. This study examines whether the Christopher evidence-based decision rule is applied in clinical practice. In addition, doctors' considerations for not applying the decision rule are explored.
Dyspnoea patients were included in the study prospectively. The diagnostic process of the patients with suspected pulmonary embolism, as judged by the treating doctor, was compared with the Christopher evidence-based decision rule using patient record reviews. In addition, 14 interviews were conducted with doctors who did not follow the Christopher evidence-based decision rule to obtain insights into their considerations.
In 80 of 247 dyspnoea cases, the treating doctors suspected pulmonary embolism. The Christopher evidence-based decision rule was applied in 17 out of 80 cases. In 22 cases, more tests were performed than was suggested by the decision rule [i.e. computer-assisted tomographic angiography (CTa) or d-dimer], while in 41 cases fewer tests were performed than suggested by the decision rule. Considerations for not following the decision rule included judging another diagnosis to be more likely and not wanting to expose the patient to CTa radiation.
The Christopher evidence-based decision rule for diagnosing pulmonary embolism was not always followed in everyday clinical practice. Doctors seem to base their diagnostic strategy on their own estimate of the likelihood of pulmonary embolism, rather than the whole decision rule. Better adherence to the decision rule could be beneficial by making doctors aware that pulmonary embolism is more likely than they initially thought. However, in a substantial number of cases, it seemed justifiable that doctors deviated from the decision rule. Therefore, further research is needed to determine the value of the Christopher evidence-based decision rule in clinical practice.