Purpose: Pulmonary embolism is a frequently missed diagnosis. The goal of the present study is to examine whether the evidence-based decisions rules to diagnose pulmonary embolism are correctly applied in clinical practice.
Method: Physicians included 247 dyspnea patients in the study. Directly after the first examination, the physicians indicated the differential diagnoses and the likelihood of those diagnoses. After the patient was discharged from the hospital, their patient records were reviewed by experts. The cases for which the physicians suspected pulmonary embolism were selected for further analysis. The diagnostic process of those cases was compared to the evidence-based decisions rules for diagnosing pulmonary embolism which are based on the Wells score. In addition, 16 interviews were conducted with physicians who did not follow the evidence-based decision rules to obtain information on the reasons why the decision rules were not applied.
Result: The results showed that in 80 out of 247 cases the physician suspected pulmonary embolism. The evidence-based decision criteria were correctly applied in 17 out of the 80 cases. In 36 cases unnecessary tests were performed to diagnose pulmonary embolism (i.e. CTa or D-dimer). While in 39 cases pulmonary embolism was not sufficiently examined, meaning that pulmonary embolism could have been missed. When the physicians were asked about their decisions they indicated that they did not want to expose the patient to the radiation of a CTa or they considered another diagnosis to be more likely assuming the patient did not have pulmonary embolism as well. Therefore they decided not to examine the patient more extensively.
Conclusion: The evidence-based decision rules are not always correctly applied in clinical practice. In a substantial number of cases in which pulmonary embolism was suspected either no diagnostic tests were performed or unnecessary diagnostic tests took place. The physicians tended to overrule the criteria when they examined a patient. Physicians should be better trained and motivated to correctly apply the evidence-based decision rules in order to improve the diagnostic process.
Candidate for the Lee B. Lusted Student Prize Competition