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The Impact of the Introduction of a Rapid D-Dimer Assay on the Diagnostic Evaluation of Suspected Pulmonary Embolism
Nir M. Goldstein, MD;
Marin H. Kollef, MD;
Suzanne Ward, RN;
Brian F. Gage, MD, MSc
Arch Intern Med. 2001;161:567-571.
Background Rapid D-dimer assays are being used in the diagnostic evaluation of
suspected pulmonary embolism (PE). Although this hypothesis is anticipated
to decrease the use of ventilation-perfusion (VQ) scans and other diagnostic
tests for PE, it has not been tested in a "real-world" environment.
Subjects and Methods A randomized prospective trial was conducted on 470 of the 5390 enrolled
patients aged 60 years and older who had previously undergone any diagnostic
tests for PE at an urban teaching hospital. The use of D-dimer as part of
the diagnostic evaluation for PE was promulgated in the 2 randomly chosen
intervention firms. The remaining 2 firms served as controls.
Main Outcome Measures The number of VQ scans, spiral computed tomographic scans, and pulmonary
angiograms performed. Secondary outcomes included mortality and thromboembolic
or bleeding events during 3 months of follow-up.
Results Of the 470 inpatients who underwent evaluation for PE on a per PE workup
basis, fewer VQ scans were performed in the intervention firms (63.8% vs 81.3%; P<.01). However, the number of patients evaluated for
PE nearly doubled in the intervention firms (304 vs 166; P<.01), so that more VQ scans were performed in the intervention
than in the control firms (194 vs 135; P<.01).
Ninety-four patients from the control firms and 160 patients from the intervention
firms were diagnosed and treated for venous thromboembolic disease (P<.01). There were no differences in secondary outcomes
during the 3-month follow-up.
Conclusions The introduction of a rapid D-dimer assay increased the number of VQ
scans performed because the number of patients screened for PE increased.
A larger number of patients in the intervention firms were diagnosed as having
venous thromboembolic disease (PE and/or deep vein thrombosis). There were
no perceived changes in mortality or venous thromboembolic events during the
3-month follow-up.
From the Pulmonary and Critical Care Division (Drs Goldstein and Kollef
and Ms Ward), Division of General Medical Sciences (Dr Gage), and Department
of Internal Medicine (Drs Goldstein, Kollef, and Gage and Ms Ward), Washington
University School of Medicine, St Louis, Mo.
Corresponding author: Marin H. Kollef, MD, Campus Box 8052, Washington
University School of Medicine, 660 S Euclid Ave, St Louis, MO 63110 (e-mail: kollefm{at}msnotes.wustl.edu).
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