Pretest risk assessment in suspected acute pulmonary embolism

Rationale and Objectives. To assess the pretest practices of US clinicians who treat patients with acute pulmonary embolism (PE). Materials and Methods. We surveyed 855 practicing physicians selected randomly from three professional organizations. We asked participants to estimate how often and by what method they determine the likelihood of PE before they request confirmatory studies. Participants reported their awareness of four published clinical practice guidelines dealing with acute PE and selected options for further diagnostic testing after reviewing clinical data from three hypothetical patients presenting with low, intermediate, and high probability of acute PE. Results. We received completed surveys from 240 physicians practicing in 44 states. Although most (98.3%) report that they assess pretest probability of PE before testing, slightly more than half do so routinely. A total of 72.5% prefer an unstructured approach to pretest assessment, whereas 22.9% use published prediction rules. Most (93.0%) are aware of at least one published guideline for assessing acute PE, but only 44.2% report using one or more in daily practice. Respondents who use published prediction rules, estimate pretest probability routinely, or use at least one practice guideline were more likely to request additional testing when reviewing a low probability clinical scenario. No differences in testing frequency or preferences were observed for intermediate or high probability clinical scenarios. Conclusions. The majority of clinicians we surveyed use an unstructured approach when estimating the pretest probability of acute PE. With the exception of low probability scenario, clinicians agreed on testing choices in suspected acute PE, regardless of the method or frequency of pre-test assessment.