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Am J Emerg Med. 2014 Dec;32(12):1499-502. doi: 10.1016/j.ajem.2014.09.027. Epub 2014 Sep 28.

Assessing 2 D-dimer age-adjustment strategies to optimize computed tomographic use in ED evaluation of pulmonary embolism.

Author information

1
Center for Evidence-Based Imaging, Brigham and Women's Hospital, Brookline, MA; Department of Radiology, Brigham and Women's Hospital, Boston, MA; Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA; Harvard Medical School, Boston, MA. Electronic address: anuraggz@gmail.com.
2
Center for Evidence-Based Imaging, Brigham and Women's Hospital, Brookline, MA; Department of Radiology, Brigham and Women's Hospital, Boston, MA; Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA; Harvard Medical School, Boston, MA.
3
Center for Evidence-Based Imaging, Brigham and Women's Hospital, Brookline, MA; Department of Radiology, Brigham and Women's Hospital, Boston, MA; Department of Medicine, Brigham and Women's Hospital, Boston, MA; Harvard Medical School, Boston, MA.
4
Center for Evidence-Based Imaging, Brigham and Women's Hospital, Brookline, MA; Department of Radiology, Brigham and Women's Hospital, Boston, MA; Harvard Medical School, Boston, MA.

Abstract

STUDY OBJECTIVE:

Validate the sensitivity and specificity of 2 age adjustment strategies for d-dimer values in identifying patients at risk for pulmonary embolism (PE) compared with traditional D-dimer cutoff value (500 ng/mL) to decrease inappropriate computed tomography pulmonary angiography (CTPA) use.

METHODS:

This institutional review board-approved, Health Insurance Portability and Accountability Act-compliant retrospective study included all adult emergency department patients evaluated for PE over a 32-month period (1/1/11-8/30/13). Only patients undergoing CTPA and D-dimer testing were included. We used a validated natural language processing algorithm to parse CTPA radiology reports and determine the presence of acute PE. Outcome measures were sensitivity and specificity of 2 age-adjusted D-dimer cutoffs compared with the traditional cutoff. We used χ2 tests with proportional analyses to assess differences in traditional and age-adjusted (age×10 ng/mL) D-dimer cutoffs, adjusting both by decade and by year.

RESULTS:

A total 3063 patients with suspected PE were evaluated by CTPA during the study period, and 1055 (34%) also received d-dimer testing. The specificity of age-adjusted D-dimer values was similar or higher for each age group studied compared with traditional cutoff, without significantly compromising sensitivity. Overall, had decade age-adjusted cutoffs been used, 37 CTPAs could have been avoided (19.6% of 189 patients aged >60 years with Wells score≤4); had yearly age-adjusted cutoffs been used, 52 CTPAs (18.2% of 286 patients aged >50 years with Wells score≤4) could have been avoided.

CONCLUSION:

Each age-adjusted D-dimer cutoff strategy for the evaluation of PE was associated with increased specificity and statistically insignificant decreased sensitivity when compared with the traditional D-dimer cutoff value.

PMID:
25303849
PMCID:
PMC4425362
DOI:
10.1016/j.ajem.2014.09.027
[Indexed for MEDLINE]
Free PMC Article

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