Emergency medicine practitioner knowledge and use of decision rules for the evaluation of patients with suspected pulmonary embolism: variations by practice setting and training level

Abstract

Background: Several clinical decision rules (CDRs) have been validated for pretest probability assessment of pulmonary embolism (PE), but the authors are unaware of any data quantifying and characterizing their use in emergency departments.

Objectives: To characterize clinicians' knowledge of and attitudes toward two commonly used CDRs for PE.

Methods: By using a modified Delphi approach, the authors developed a two-page paper survey including 15 multiple-choice questions. The questions were designed to determine the respondents' familiarity, frequency of use, and comprehension of the Canadian and Charlotte rules. The survey also queried the frequency of use of unstructured (gestalt) pretest probability assessment and reasons why physicians choose not to use decision rules. The surveys were sent to physicians, physician assistants, and medical students at 32 academic and community hospitals in the United States and the United Kingdom.

Results: Respondents included 555 clinicians; 443 (80%) work in academic practice, and 112 (20%) are community based. Significantly more academic practitioners (73%) than community practitioners (49%) indicated familiarity with at least one of the two decision rules. Among all respondents familiar with a rule, 50% reported using it in more than half of applicable cases. A significant number of these respondents could not correctly identify a key component of the rule (23% for the Charlotte rule and 43% for the Canadian rule). Fifty-seven percent of all respondents indicated use of gestalt rather than a decision rule in more than half of cases.

Conclusions: Academic clinicians were more likely to report familiarity with either of these two specific decision rules. Only one half of all clinicians reporting familiarity with the rules use them in more than 50% of applicable cases. Spontaneous recall of the specific elements of the rules was low to moderate. Future work should consider clinical gestalt in the evaluation of patients with possible PE.