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

Rosanne van Maanen¹, Emily S L Martens², Toshihiko Takada³, Pierre-Marie Roy⁴, Kerstin de Wit⁵, Sameer Parpia⁶, Noémie Kraaijpoel⁷, Menno V Huisman⁸, Philip S Wells⁹, Grégoire Le Gal⁹, Marc Righini¹⁰, Yonathan Freund¹¹, Javier Galipienzo¹², Nick van Es¹³, Jeanet W Blom¹⁴, Karel G M Moons¹⁵, Frans H Rutten¹⁶, Maarten van Smeden¹⁵, Frederikus A Klok⁸, Geert-Jan Geersing¹⁶, Kim Luijken¹⁵

Affiliations

¹ Department of General Practice, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands. Electronic address: r.vanmaanen@umcutrecht.nl.
² Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands. Electronic address: https://twitter.com/ESLmartens.
³ Department of General Medicine, Shirakawa Satellite for Teaching And Research (STAR), Fukushima Medical University, Fukushima, Japan.
⁴ Department of Emergency Medicine, Angers University Hospital; MitoVasc UMR CNRS 6015 - INSERM 1083, Université Angers, Angers; and French Clinical Research Infrastructure (F-CRIN) Network, INvestigation Network On Venous Thrombo-Embolism (INNOVTE), Saint-Etienne, France.
⁵ Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada; Department of Emergency Medicine, Queen's University, Kingston, Canada.
⁶ Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada; Department of Oncology, McMaster University, Hamilton, Canada.
⁷ Department of Medicine, Amsterdam University Medical Center, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands.
⁸ Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands.
⁹ Department of Medicine, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, Canada.
¹⁰ Division of Angiology and Hemostasis, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland.
¹¹ Sorbonne University, Emergency Department, Hopital Pitie-Salpêtrière, Assistance Publique-Hopitaux de Paris, Paris, France.
¹² Service of Anesthesiology, MD Anderson Cancer Center Madrid, Madrid, Spain.
¹³ Amsterdam UMC location University of Amsterdam, Department of Vascular Medicine, Meibergdreef 9, Amsterdam, the Netherlands; Amsterdam Cardiovascular Sciences, Pulmonary Hypertension & Thrombosis, Amsterdam, the Netherlands.
¹⁴ Department of General Practice, Leiden University Medical Center, Leiden, the Netherlands.
¹⁵ Department of Epidemiology, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands.
¹⁶ Department of General Practice, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands.

PMID: 37263381
DOI: 10.1016/j.jtha.2023.05.023

Free article

Meta-Analysis

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

Rosanne van Maanen et al. J Thromb Haemost. 2023 Oct.

Free article

. 2023 Oct;21(10):2873-2883.

doi: 10.1016/j.jtha.2023.05.023. Epub 2023 May 30.

Authors

Affiliations

¹ Department of General Practice, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands. Electronic address: r.vanmaanen@umcutrecht.nl.
² Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands. Electronic address: https://twitter.com/ESLmartens.
³ Department of General Medicine, Shirakawa Satellite for Teaching And Research (STAR), Fukushima Medical University, Fukushima, Japan.
⁴ Department of Emergency Medicine, Angers University Hospital; MitoVasc UMR CNRS 6015 - INSERM 1083, Université Angers, Angers; and French Clinical Research Infrastructure (F-CRIN) Network, INvestigation Network On Venous Thrombo-Embolism (INNOVTE), Saint-Etienne, France.
⁵ Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada; Department of Emergency Medicine, Queen's University, Kingston, Canada.
⁶ Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada; Department of Oncology, McMaster University, Hamilton, Canada.
⁷ Department of Medicine, Amsterdam University Medical Center, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands.
⁸ Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands.
⁹ Department of Medicine, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, Canada.
¹⁰ Division of Angiology and Hemostasis, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland.
¹¹ Sorbonne University, Emergency Department, Hopital Pitie-Salpêtrière, Assistance Publique-Hopitaux de Paris, Paris, France.
¹² Service of Anesthesiology, MD Anderson Cancer Center Madrid, Madrid, Spain.
¹³ Amsterdam UMC location University of Amsterdam, Department of Vascular Medicine, Meibergdreef 9, Amsterdam, the Netherlands; Amsterdam Cardiovascular Sciences, Pulmonary Hypertension & Thrombosis, Amsterdam, the Netherlands.
¹⁴ Department of General Practice, Leiden University Medical Center, Leiden, the Netherlands.
¹⁵ Department of Epidemiology, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands.
¹⁶ Department of General Practice, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands.

PMID: 37263381
DOI: 10.1016/j.jtha.2023.05.023

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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Conflict of interest statement

Declaration of competing interests There are no competing interests to disclose.

Comment in

Clinical gestalt in identifying pulmonary embolism: does one size fit all?
Zhu YJ, Huo Y. Zhu YJ, et al. J Thromb Haemost. 2023 Oct;21(10):2702-2704. doi: 10.1016/j.jtha.2023.06.030. J Thromb Haemost. 2023. PMID: 37739587 No abstract available.

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

Affiliations

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

Authors

Affiliations

Abstract

Conflict of interest statement

Comment in

Publication types

MeSH terms

LinkOut - more resources

Full Text Sources

Medical