Accuracy of physicians’ intuitive risk estimation in the diagnostic management of pulmonary embolism: an individual patient data meta-analysis

פוסט זה זמין גם ב: עברית

Rosanne van Maanen 1Emily S L Martens 2Toshihiko Takada 3Pierre-Marie Roy 4Kerstin de Wit 5Sameer Parpia 6Noémie Kraaijpoel 7Menno V Huisman 8Philip S Wells 9Grégoire Le Gal 9Marc Righini 10Yonathan Freund 11Javier Galipienzo 12Nick van Es 13Jeanet W Blom 14Karel G M Moons 15Frans H Rutten 16Maarten van Smeden 15Frederikus A Klok 8Geert-Jan Geersing 16Kim Luijken 15

Abstract           

Background: In patients clinically suspected of having pulmonary embolism (PE), physicians often rely on intuitive estimation (“gestalt”) of PE presence. Although shown to be predictive, gestalt is criticized for its assumed variation across physicians and lack of standardization.

Objectives: To assess the diagnostic accuracy of gestalt in the diagnosis of PE and gain insight into its possible variation.

Methods: We performed an individual patient data meta-analysis including patients suspected of having PE. The primary outcome was diagnostic accuracy of gestalt for the diagnosis of PE, quantified as risk ratio (RR) between gestalt and PE based on 2-stage random-effect log-binomial meta-analysis regression as well as gestalts’ sensitivity and specificity. The variability of these measures was explored across different health care settings, publication period, PE prevalence, patient subgroups (sex, heart failure, chronic lung disease, and items of the Wells score other than gestalt), and age.

Results: We analyzed 20 770 patients suspected of having PE from 16 original studies. The prevalence of PE in patients with and without a positive gestalt was 28.8% vs 9.1%, respectively. The overall RR was 3.02 (95% CI, 2.35-3.87), and the overall sensitivity and specificity were 74% (95% CI, 68%-79%) and 61% (95% CI, 53%-68%), respectively. Although variation was observed across individual studies (I2, 90.63%), the diagnostic accuracy was consistent across all subgroups and health care settings.

Conclusion: A positive gestalt was associated with a 3-fold increased risk of PE in suspected patients. Although variation was observed across studies, the RR of gestalt was similar across prespecified subgroups and health care settings, exemplifying its diagnostic value for all patients suspected of having PE.

Keywords: diagnosis; pulmonary embolism; venous thromboembolism; venous thrombosis.

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