Annals of Emergency Medicine
Volume 56, Issue 4 , Pages 321-332.e10 , October 2010

Cost-Effectiveness of Strategies for Diagnosing Pulmonary Embolism Among Emergency Department Patients Presenting With Undifferentiated Symptoms

  • Ram S. Duriseti, MD, PhD

      Affiliations

    • Department of Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, and the Division of Emergency Medicine, Department of Surgery, Stanford University, Stanford, CA
    • Corresponding Author InformationAddress for correspondence: Ram Duriseti, MD, PhD, Division of Emergency Medicine, Stanford University Hospitals and Clinics, 701 Welch Rd, Ste C, Palo Alto, CA 94304; 650-521-4517
    • ,
  • Margaret L. Brandeau, PhD

      Affiliations

    • Department of Management Science and Engineering, Stanford University, Stanford, CA

Received 2 September 2009 ,Revised 10 March 2010 ,Accepted 22 March 2010.

References 

  1. Ageno W, Squizzato A, Garcia D, et al. Epidemiology and risk factors of venous thromboembolism. Semin Thromb Hemost. 2006;32:651–658
  2. Anderson D. A population-based perspective of the hospital incidence and case-fatality rates of deep vein thrombosis and pulmonary embolism (The Worcester DVT Study). Arch Intern Med. 1991;151:933–938
  3. Arcelus J, Caprini J, Monreal M, et al. The management and outcome of acute venous thromboembolism: a prospective registry including 4011 patients. J Vasc Surg. 2003;38:916–922
  4. Calder K, Herbert M, Henderson S. The mortality of untreated pulmonary embolism in emergency department patients. Ann Emerg Med. 2005;45:302–310
  5. Cosmi B, Palareti G. Oral anticoagulant therapy in venous thromboembolism. Semin Vasc Med. 2003;3:303–314
  6. Cushman M. Epidemiology and risk factors for venous thrombosis. Semin Hematol. 2007;44:62–69
  7. Dalen J, Alpert J. Natural history of pulmonary embolism. Prog Cardiovasc Dis. 1975;17:259–270
  8. Heit JA. Venous thromboembolism: disease burden, outcomes and risk factors. J Thromb Haemost. 2005;3:1611–1617
  9. Macdougall DA, Feliu AL, Boccuzzi SJ, et al. Economic burden of deep-vein thrombosis, pulmonary embolism, and post-thrombotic syndrome. Am J Health Syst Pharm. 2006;63(20 suppl 6):S5–S15
  10. Michota F. Venous thromboembolism: epidemiology, characteristics, and consequences. Clin Cornerstone. 2005;7:8–15
  11. Nijkeuter M, Söhne M, Tick L, et al. The natural course of hemodynamically stable pulmonary embolism: clinical outcome and risk factors in a large prospective cohort study. Chest. 2007;131:517–523
  12. Ribeiro A, Lindmarker P, Johnsson H, et al. Pulmonary embolism: one-year follow-up with echocardiography doppler and five-year survival analysis. Circulation. 1999;99:1325–1330
  13. Schulman S, Lindmarker P, Holmström M, et al. Post-thrombotic syndrome, recurrence, and death 10 years after the first episode of venous thromboembolism treated with warfarin for 6 weeks or 6 months. J Thromb Haemost. 2006;4:734–742
  14. de Moerloose P, Bounameaux H, Perrier A, et al. Performances of the VIDAS D-dimer new assay for the exclusion of venous thromboembolism. Thromb Haemost. 2001;85:185–186
  15. Galle C, Papazyan J, Miron M, et al. Prediction of pulmonary embolism extent by clinical findings, D-dimer level and deep vein thrombosis shown by ultrasound. Thromb Haemost. 2001;86:1156–1160
  16. [package insert] Vidas D-dimer new (DD2). France: bioMerieux; 2002;
  17. Kruip M, Slob M, Schijen J, et al. Use of a clinical decision rule in combination with D-dimer concentration in diagnostic workup of patients with suspected pulmonary embolism: a prospective management study. Arch Intern Med. 2002;162:1631–1635
  18. Brill-Edwards P, Lee A. D-dimer testing in the diagnosis of acute venous thromboembolism. Thromb Haemost. 1999;82:688–694
  19. Freyburger G, Trillaud H, Labrouche S, et al. D-dimer strategy in thrombosis exclusion—a gold standard study in 100 patients suspected of deep venous thrombosis or pulmonary embolism: 8 DD methods compared. Thromb Haemost. 1998;79:32–37
  20. Sijens P, Oudkerk M. Exclusion of pulmonary embolism using quantitative plasma D-dimer assays. Clin Lab. 2001;47:321–326
  21. Wells P, Anderson D, Rodger M, et al. Derivation of a simple clinical model to categorize patients probability of pulmonary embolism: increasing the models utility with the SimpliRED D-dimer. Thromb Haemost. 2000;83:416–420
  22. Kline J, Nelson R, Jackson R, et al. Criteria for the safe use of D-dimer testing in emergency department patients with suspected pulmonary embolism: a multicenter US study. Ann Emerg Med. 2002;39:144–152
  23. Gibson NS, Sohne M, Kruip MJHA, et al. Further validation and simplification of the Wells clinical decision rule in pulmonary embolism. Thromb Haemost. 2008;99:229–234
  24. Wolf S, McCubbin T, Feldhaus K, et al. Prospective validation of Wells criteria in the evaluation of patients with suspected pulmonary embolism. Ann Emerg Med. 2004;44:503–510
  25. Wells P, Ginsberg J, Anderson D, et al. Use of a clinical model for safe management of patients with suspected pulmonary embolism. Ann Intern Med. 1998;129:997–1005
  26. Michel B, Seerden R, Rutten F, et al. The cost-effectiveness of diagnostic strategies in patients with suspected pulmonary embolism. Health Econ. 1996;5:307–318
  27. van Erkel A, van Rossum A, Bloem J, et al. Spiral CT angiography for suspected pulmonary embolism: a cost-effectiveness analysis. Radiology. 1996;201:209–236
  28. Paterson D, Schwartzman K. Strategies incorporating spiral CT for the diagnosis of acute pulmonary embolism: a cost-effectiveness analysis. Chest. 2001;199:1791–1800
  29. Oudkerk M, van Beek E, van Putten W, et al. Cost-effectiveness analysis of various strategies in the diagnostic management of pulmonary embolism. Arch Intern Med. 1993;153:947–954
  30. Duriseti R, Shachter R, Brandeau M. Value of quantitative D-dimer assays in identifying pulmonary embolism: implications from a sequential decision model. Acad Emerg Med. 2006;13:755–766
  31. Barrellier M, Lezin B, Landy S, et al. [Prevalence of duplex ultrasonography detectable venous thrombosis in patients with suspected or acute pulmonary embolism]. J Malays Vasc Surg. 2001;26:23–30
  32. Girard P, Decousus M, Laporte S, et al. Diagnosis of pulmonary embolism in patients with proximal deep vein thrombosis: specificity of symptoms and perfusion defects at baseline and during anticoagulant therapy. Am J Respir Crit Care Med. 2001;164:1033–1037
  33. Heckerman D, Shachter R. Decision-theoretic foundations for causal reasoning. J Artific Intell Res. 1995;3:405–430
  34. Kabrhel C, McAfee A, Goldhaber S. The probability of pulmonary embolism is a function of the diagnoses considered most likely before testing. Acad Emerg Med. 2006;13:471–474
  35. Kohn M, Kwan E, Gupta M, et al. Prevalence of acute myocardial infarction and other serious diagnoses in patients presenting to an urban emergency department with chest pain. J Emerg Med. 2005;29:383–390
  36. Testuz A, Le Gal G, Righini M, et al. Influence of specific alternative diagnoses on the probability of pulmonary embolism. Thromb Haemost. 2006;95:958–962
  37. Ohlmann P, Faure A, Morel O, et al. Diagnostic and prognostic value of circulating D-dimers in patients with acute aortic dissection. Crit Care Med. 2006;34:1358–1364
  38. Shilon Y, Shitrit A, Rudensky B, et al. A rapid quantitative D-dimer assay at admission correlates with the severity of community acquired pneumonia. Blood Coagul Fibrinolysis. 2003;14:745–748
  39. Querol-Ribelles J, Tenias J, Grau E, et al. Plasma D-dimer levels correlate with outcomes in patients with community-acquired pneumonia. Chest. 2004;126:1087–1092
  40. Weber T, Högler S, Auer J, et al. D-dimer in acute aortic dissection. Chest. 2003;123:1375–1378
  41. Shitrit D, Shitrit A, Rudensky B, et al. Determinants of ELISA D-dimer sensitivity for unstable angina pectoris as defined by coronary catheterization. Am J Hematol. 2004;76:121–125
  42. Akutsu K, Sato N, Yamamoto T, et al. A rapid bedside D-dimer assay (cardiac D-dimer) for screening of clinically suspected acute aortic dissection. Circ J. 2005;69:397–403
  43. Sbarouni K, Georgiadou K, Marathias K, et al. D-dimer and BNP levels in acute aortic dissection. Int J Cardiol. 2007;122:170–172
  44. Kiernan TJ. Aortic dissection and elevated D-dimers—an important clinical link. Int J Cardiol. 2007;114:E77–E78
  45. Castro DJ, Perez-Rodriguez E, Montaner L, et al. Diagnostic value of D dimer in pulmonary embolism and pneumonia. Respiration. 2001;68:371–375
  46. Güneysel O, Pirmit S, Karakurt S. Plasma D-dimer levels increase with the severity of community acquired pneumonia. Tuberk Toraks. 2004;52:341–347
  47. Di Nisio M, Sohne M, Kamphuisen PW, et al. D-dimer test in cancer patients with suspected acute pulmonary embolism. J Thromb Haemost. 2005;3:1239–1242
  48. Righini M, Le Gal G, De Lucia S, et al. Clinical usefulness of D-dimer testing in cancer patients with suspected pulmonary embolism. Thromb Haemost. 2006;95:715–719
  49. Di Nisio M, Rutjes AWS, Buller HR. Combined use of clinical pretest probability and D-dimer test in cancer patients with clinically suspected deep venous thrombosis. J Thromb Haemost. 2006;4:52–57
  50. Righini M, de Moerloose P, Reber G, et al. Should the D-dimer cut-off value be increased in elderly patients suspected of pulmonary embolism?. Thromb Haemost. 2001;85:744
  51. PIOPED. Comprehensive analysis of the results of the PIOPED study (Prospective Investigation of Pulmonary Embolism Diagnosis Study). J Nucl Med. 1995;36:2380–2387
  52. Peters K, Kochanek K, Murphy S. Deaths: final data for 1996. Natl Vital Stat Rep. 1998;47:1–100
  53. Wells P, Anderson D, Rodger M, et al. Excluding pulmonary embolism at the bedside without diagnostic imaging: management of patients with suspected pulmonary embolism presenting to the emergency department by using a simple clinical model and D-dimer. Ann Intern Med. 2001;135:98–107
  54. Klok F, Karami D, Nijkeuter M, et al. Alternative diagnosis other than pulmonary embolism as a subjective variable in the Wells clinical decision rule: not so bad after all. J Thromb Haemost. 2007;5:1079–1080
  55. Moores L, Collen J, Woods K, et al. Practical utility of clinical prediction rules for suspected acute pulmonary embolism in a large academic institution. Thromb Res. 2004;113:1–6
  56. Burt C. Summary statistics for acute cardiac ischemia and chest pain visits to United States EDs, 1995-1996. Am J Emerg Med. 1999;17:552–559
  57. Goodacre S, Arnold J, Revill S, et al. Clinical predictors of acute coronary syndromes in patients with undifferentiated chest pain. QJM. 2003;96:893–898
  58. Karlson B, Herlitz J, Pettersson P, et al. Patients admitted to the emergency room with symptoms indicative of acute myocardial infarction. J Intern Med. 1991;230:251–258
  59. Tierney W, Fitzgerald J, McHenry R, et al. Physicians' estimates of the probability of myocardial infarction in emergency room patients with chest pain. Med Decis Making. 1986;6:12–17
  60. Pope J, Aufderheide T, Ruthazer R, et al. Missed diagnoses of acute cardiac ischemia in the emergency department. N Engl J Med. 2000;342:1163–1170
  61. McCaig L, Burt C. National Hospital Ambulatory Medical Care Survey: 2002 emergency department summary. Adv Data. 2004;340:1–34
  62. Richman P, Courtney D, Friese J, et al. Prevalence and significance of nonthromboembolic findings on chest computed tomography angiography performed to rule out pulmonary embolism: a multicenter study of 1,025 emergency department patients. Acad Emerg Med. 2004;11:642–647
  63. Bulger CM, Jacobs C, Patel NH. Epidemiology of acute deep vein thrombosis. Tech Vasc Interv Radiol. 2004;7:50–54
  64. Borst-Krafek B, Fink A, Lipp C, et al. Proximal extent of pelvic vein thrombosis and its association with pulmonary embolism. J Vasc Surg. 2003;37:518–522
  65. Cham MD, Yankelevitz DF, Henschke C. Thromboembolic disease detection at indirect CT venography versus CT pulmonary angiography. Radiology. 2005;234:591–594
  66. Cushman M, Tsai A, White R, et al. Deep vein thrombosis and pulmonary embolism in two cohorts: the longitudinal investigation of thromboembolism etiology. Am J Med. 2004;117:19–25
  67. Gaitini D. Current approaches and controversial issues in the diagnosis of deep vein thrombosis via duplex Doppler ultrasound. J Clin Ultrasound. 2006;34:289–297
  68. Johanning J, Franklin D, Thomas D, et al. D-dimer and calf circumference in the evaluation of outpatient deep venous thrombosis. J Vasc Surg. 2002;36:877–880
  69. Loud P, Katz D, Bruce D, et al. Deep venous thrombosis with suspected pulmonary embolism: detection with combined CT venography and pulmonary angiography. Radiology. 2001;219:498–502
  70. Markel A. Origin and natural history of deep vein thrombosis of the legs. Semin Vasc Med. 2005;5:65–74
  71. Baarslag H, Koopman M, Hutten B, et al. Long-term follow-up of patients with suspected deep vein thrombosis of the upper extremity: survival, risk factors and post-thrombotic syndrome. Eur J Intern Med. 2004;15:503–507
  72. Joffe HV, Kucher N, Tapson VF, et al. Upper-extremity deep vein thrombosis: a prospective registry of 592 patients. Circulation. 2004;110:1605–1611
  73. Stein P, Henry J, Gopalakrishnan D, et al. Asymmetry of the calves in the assessment of patients with suspected acute pulmonary embolism. Chest. 1995;107:936–939
  74. Wells P, Hirsh J, Anderson D, et al. Accuracy of clinical assessment of deep-vein thrombosis. Lancet. 1995;345:1326–1330
  75. Kearon C. Natural history of venous thromboembolism. Circulation. 2003;107(suppl 1):i22–i30
  76. Modan B, Sharon E, Jelin N. Factors contributing to the incorrect diagnosis of pulmonary embolic disease. Chest. 1972;62:388–393
  77. Shitrit A, Tzivony D, Shilon Y, et al. The role of enzyme-linked immunosorbent assay D-dimer in patients with acute coronary syndrome presenting with normal cardiac enzymes. Blood Coagul Fibrinolysis. 2006;17:621–624
  78. de Monye W, Sanson B, Buller H, et al. The performance of two rapid quantitative D-dimer assays in 287 patients with clinically suspected pulmonary embolism. Thromb Res. 2002;107:283–286
  79. Duet M, Benelhadj S, Kedra W, et al. A new quantitative D-dimer assay appropriate in emergency: reliability of the assay for pulmonary embolism exclusion diagnosis. Thromb Res. 1998;91:1–5
  80. Risch L, Monn A, Lüthy R, et al. The predictive characteristics of D-dimer testing in outpatients with suspected venous thromboembolism: a bayesian approach. Clin Chim Acta. 2004;345:79–87
  81. Wells P, Anderson D. Diagnosis of deep-vein thrombosis in the year 2000. Curr Opin Pulm Med. 2000;6:309–313
  82. Peterson D, Kazerooni E, Wakefield T, et al. Computed tomographic venography is specific but not sensitive for diagnosis of acute lower-extremity deep venous thrombosis in patients with suspected pulmonary embolus. J Vasc Surg. 2001;34:798–804
  83. Richman P, Wood J, Kasper D, et al. Contribution of indirect computed tomography venography to computed tomography angiography of the chest for the diagnosis of thromboembolic disease in two United States emergency departments. J Thromb Haemost. 2003;1:652–657
  84. Stein P, Woodard P, Weg J, et al. Diagnostic pathways in acute pulmonary embolism: recommendations of the PIOPED II investigators. Am J Med. 2006;119:1048–1055
  85. Theodorou S, Theodorou D, Kakitsubata Y. Sonography and venography of the lower extremities for diagnosing deep vein thrombosis in symptomatic patients. Clin Imaging. 2003;27:180–183
  86. Adams F. The role of spiral computed tomography and D-dimer in pulmonary embolism. Scott Med J. 2001;46:7–8
  87. Perrier A, Howarth N, Didier D, et al. Performance of helical computed tomography in unselected outpatients with suspected pulmonary embolism. Ann Intern Med. 2001;135:88–97
  88. Burkill G, Bell J, Chinn R, et al. The use of a D-dimer assay in patients undergoing CT pulmonary angiography for suspected pulmonary embolus. Clin Radiol. 2002;57:41–46
  89. Nilsson T, Soderberg M, Lundqvist G, et al. A comparison of spiral computed tomography and latex agglutination D-dimer assay in acute pulmonary embolism using pulmonary arteriography as gold standard. Scand Cardiovasc J. 2002;36:373–377
  90. Safriel Y, Zinn H. CT pulmonary angiography in the detection of pulmonary emboli: a meta-analysis of sensitivities and specificities. Clin Imaging. 2002;26:101–105
  91. Stein P, Fowler S, Goodman L, et al. Multidetector computed tomography for acute pulmonary embolism. N Engl J Med. 2006;354:2317–2327
  92. Ralph D. Pulmonary embolism (The implications of prospective investigation of pulmonary embolism diagnosis). Radiol Clin North Am. 1994;32:679–687
  93. Goodacre S, Sampson F, Stevenson M, et al. Measurement of the clinical and cost-effectiveness of non-invasive diagnostic testing strategies for deep vein thrombosis. Health Technol Assess (Rockv). 2006;10:1–168iii
  94. Hingorani A, Ascher E, Markevich N, et al. Prospective evaluation of combined upper and lower extremity DVT. Vasc Endovascular Surg. 2006;40:131–134
  95. Agency for Healthcare Research and Quality. Diagnosis and Treatment of Deep Venous Thrombosis and Pulmonary Embolism. Summary, Evidence Report/Technology Assessment: Number 68. Rockville, MD: Agency for Healthcare Research and Quality; 2003;
  96. PIOPED. Value of the ventilation/perfusion scan in acute pulmonary embolism (Results of the Prospective Investigation of Pulmonary Embolism Diagnosis (PIOPED). The PIOPED investigators). JAMA. 1990;263:2753–2759
  97. PIOPED. Ventilation-perfusion scintigraphy in the PIOPED study. J Nucl Med. 1993;34:1109–1126
  98. Goris M. PIOPED likelihood ratios. [letter] JAMA. 1990;264:2623–2625
  99. Gold M, Siegel J, Russell L. Cost-effectiveness in Health and Medicine. New York, NY: Oxford University Press; 1996;
  100. Bick RL. Proficient and cost-effective approaches for the prevention and treatment of venous thrombosis and thromboembolism. Drugs. 2000;60:575–595
  101. Cosmi B, Palareti G. Extended treatment for venous thromboembolism: how long is long enough?. Curr Hematol Rep. 2004;3:375–381
  102. Centers for Medicare & Medicaid Services. Medicare program: payments for new medical services and new technologies under the acute care hospital inpatient prospective payment system (Final rule). Fed Reg. 2001;66:46901–46925
  103. Keeling D. Duration of anticoagulation: decision making based on absolute risk. Blood Rev. 2006;20:173–178
  104. van Erkel A, van den Hout W, Pattynama P. International differences in health care costs in Europe and the United States: do these affect the cost-effectiveness of diagnostic strategies for pulmonary embolism?. Eur J Radiol. 1999;9:1926–1931
  105. Hull R, Pineo G, Stein P, et al. Cost-effectiveness of currently accepted strategies for pulmonary embolism diagnosis. Semin Thromb Hemost. 2001;27:15–23
  106. Perrier A, Nendaz M, Sarasin F, et al. Cost-effectiveness analysis of diagnostic strategies for suspected pulmonary embolism including helical computed tomography. Am J Respir Crit Care Med. 2003;167:39–44
  107. Tsai A, Tamayo-Sarver J, Cydulka R, et al. Declining payments for emergency department care, 1996-1998. Ann Emerg Med. 2003;41:299–308
  108. Taylor H. Most doctors report fear of malpractice liability has harmed their ability to provide quality care: caused them to order unnecessary tests, provide unnecessary treatment and make unnecessary referrals. Harris Interactive Inc. http://www.harrisinteractive.com/harris_poll/index.asp?PID=300Accessed June 26, 2008
  109. Perroni S. The anatomy of a medical negligence case involving venous thrombosis, pulmonary embolism and legal causation. Med Trial Tech Q. 1975;22:8–51
  110. Karcz A, Holbrook J, Auerbach B, et al. Preventability of malpractice claims in emergency medicine: a closed claims study. Ann Emerg Med. 1990;19:865–873
  111. Karcz A, Korn R, Burke M, et al. Malpractice claims against emergency physicians in Massachusetts: 1975-1993. Am J Emerg Med. 1996;14:341–345
  112. Fink S, Chaudhuri T, Davis H. Pulmonary embolism and malpractice claims. South Med J. 1998;91:1149–1152
  113. McCaig L, Burt C. National Ambulatory Medical Care Survey: 2001 emergency department summary. Adv Data. 2003;(335):1–29
  114. Tengs T, Wallace A. One thousand health-related quality-of-life estimates. Med Care. 2000;38:583–637
  115. Hingorani A, Ascher E, Marks N, et al. Morbidity and mortality associated with brachial vein thrombosis. Ann Vasc Surg. 2006;20:297–300
  116. Prandoni P, Villalta S, Bagatella P, et al. The clinical course of deep-vein thrombosis (Prospective long-term follow-up of 528 symptomatic patients). Haematologica. 1997;82:423–428
  117. Revicki DA. National health preference data: a useful resource for health services research. Med Decis Making. 2006;26:310–312
  118. Bova C, Rossi V, Ricchio R, et al. Incidence of post-thrombotic syndrome in patients with previous pulmonary embolism (A retrospective cohort study). Thromb Haemost. 2004;92:993–996
  119. Stein P, Kayali F, Olson R. Estimated case fatality rate of pulmonary embolism, 1979 to 1998. Am J Cardiol. 2004;93:1197–1199
  120. Stein P, Kayali F, Olson R. Regional differences in rates of diagnosis and mortality of pulmonary thromboembolism. Am J Cardiol. 2004;93:1194–1197
  121. Kahn S, Elman E, Bornais C, et al. Post-thrombotic syndrome, functional disability and quality of life after upper extremity deep venous thrombosis in adults. Thromb Haemost. 2005;93:499–502
  122. Ghaye B, Nchimi A, Noukoua C, et al. Does multi-detector row CT pulmonary angiography reduce the incremental value of indirect CT venography compared with single-detector row CT pulmonary angiography?. Radiology. 2006;240:256–262
  123. Yamaki T, Nozaki M, Sakurai H, et al. Uses of different D-dimer levels can reduce the need for venous duplex scanning to rule out deep vein thrombosis in patients with symptomatic pulmonary embolism. J Vasc Surg. 2007;46:526–532
  124. Kabrhel C, Mark Courtney D, Camargo CJ, et al. Potential impact of adjusting the threshold of the quantitative D-dimer based on pretest probability of acute pulmonary embolism. Acad Emerg Med. 2009;16:325–332
  125. Kabrhel C, Matts C, McNamara M, et al. A highly sensitive ELISA D-dimer increases testing but not diagnosis of pulmonary embolism. Acad Emerg Med. 2006;13:519–524
  126. Cornuz J, Ghali W, Hayoz D, et al. Clinical prediction of deep venous thrombosis using two risk assessment methods in combination with rapid quantitative D-dimer testing. Am J Med. 2002;112:198–203
  127. Oger E, Leroyer C, Bressollette L, et al. Evaluation of a new, rapid, and quantitative D-Dimer test in patients with suspected pulmonary embolism. Am J Respir Crit Care Med. 1998;158:65–70
  128. Reber G, Bounameaux H, Perrier A, et al. Evaluation of advanced D-dimer assay for the exclusion of venous thromboembolism. Thromb Res. 2002;107:197–200
  129. Tardy B, Tardy P, Viallon A, et al. Evaluation of D-dimer ELISA test in elderly patients with suspected pulmonary embolism. Thromb Haemost. 1998;79:38–41
  130. Naess I, Christiansen S, Romundstad P, et al. Incidence and mortality of venous thrombosis: a population-based study. J Thromb Haemost. 2007;5:692–699
  131. Thomas L, Reichl M. Pulmonary embolism in patients attending the accident and emergency department with pleuritic chest pain. Arch Emerg Med. 1991;8:48–51
  132. White RH. The epidemiology of venous thromboembolism. Circulation. 2003;107(23 suppl 1):I4–I8
  133. Kline JA, Courtney DM, Kabrhel C, et al. Prospective multicenter evaluation of the pulmonary embolism rule-out criteria. J Thromb Haemost. 2008;6:772–780
  134. Righini M, Le Gal G, Aujesky D, et al. Diagnosis of pulmonary embolism by multidetector CT alone or combined with venous ultrasonography of the leg: a randomised non-inferiority trial. Lancet. 2008;371:1343–1352
  135. Turkstra F, Kuijer PM, van Beek EJ, et al. Diagnostic utility of ultrasonography of leg veins in patients suspected of having pulmonary embolism. Ann Intern Med. 1997;126:775–781
  136. Michiels JJ, Gadisseur A, van der Planken M, et al. Screening for deep vein thrombosis and pulmonary embolism in outpatients with suspected DVT or PE by the sequential use of clinical score: a sensitive quantitative D-dimer test and noninvasive diagnostic tools. Semin Vasc Med. 2005;5:351–364
  137. Le Gal G, Righini M, Sanchez O, et al. A positive compression ultrasonography of the lower limb veins is highly predictive of pulmonary embolism on computed tomography in suspected patients. Thromb Haemost. 2006;95:963–966
  138. Girard P, Sanchez O, Leroyer C, et al. Deep venous thrombosis in patients with acute pulmonary embolism: prevalence, risk factors, and clinical significance. Chest. 2005;128:1593–1600
  139. Le Gal G, Righini M, Roy P, et al. Prediction of pulmonary embolism in the emergency department: the revised Geneva score. Ann Intern Med. 2006;144:165–171
  140. Siegel JE, Weinstein MC, Russell LB, et al. Recommendations for reporting cost-effectiveness analyses (Panel on Cost-effectiveness in Health and Medicine). JAMA. 1996;276:1339–1341
  141. Trujillo-Santos J, Herrera S, Page MA, et al. Predicting adverse outcome in outpatients with acute deep vein thrombosis (findings from the RIETE Registry). J Vasc Surg. 2006;44:789–793
  142. Mitchell A, Kline J. Contrast nephropathy following computed tomography angiography of the chest for pulmonary embolism in the emergency department. J Thromb Haemost. 2007;5:50–54

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 Author contributions: RSD was responsible for model conception, research, coding, analytics, and the article. MLB was responsible for advising, article reviews, and rewriting. RSD and MLB were responsible for figure construction. RSD had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. RSD takes responsibility for the paper as a whole.

 Funding and support: By Annals policy, all authors are required to disclose any and all commercia, financial, and other relationships in any way related to the subject of this article that might create any potential conflict of interest. See the Manuscript Submission Agreement in this issue for examples of specific conflicts covered by this agreement. Dr. Duriseti was supported by a Postdoctoral Fellowship from the Department of Veterans Affairs. Dr. Brandeau is supported by grant R01-DA15612 from the National Institute on Drug Abuse.

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PII: S0196-0644(10)00276-3

doi: 10.1016/j.annemergmed.2010.03.029

Annals of Emergency Medicine
Volume 56, Issue 4 , Pages 321-332.e10 , October 2010

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