TY - JOUR
T1 - Accuracy of physicians' intuitive risk estimation in the diagnostic management of pulmonary embolism
T2 - An Individual Patient Data Meta-Analysis
AU - Maanen, Rosanne van
AU - Martens, Emily S L
AU - Takada, Toshihiko
AU - Roy, Pierre-Marie
AU - de Wit, Kerstin
AU - Parpia, Sameer
AU - Kraaijpoel, Noémie
AU - Huisman, Menno V
AU - Wells, Philip S
AU - Le Gal, Grégoire
AU - Righini, Marc
AU - Freund, Yonathan
AU - Galipienzo, Javier
AU - van Es, Nick
AU - Blom, Jeanet W
AU - Moons, Karel G M
AU - Rutten, Frans H
AU - Smeden, Maarten van
AU - Klok, Frederikus A
AU - Geersing, Geert-Jan
AU - Luijken, Kim
N1 - Funding Information:
Funding information Geert-Jan Geersing is supported by a personal Vidi grant from the Dutch Research Council (grant number 91719304 ). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Publisher Copyright:
© 2023 The Authors
PY - 2023/10
Y1 - 2023/10
N2 - 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 (I
2, 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.
AB - 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 (I
2, 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.
KW - diagnosis
KW - pulmonary embolism
KW - venous thromboembolism
KW - venous thrombosis
UR - http://www.scopus.com/inward/record.url?scp=85165660833&partnerID=8YFLogxK
U2 - 10.1016/j.jtha.2023.05.023
DO - 10.1016/j.jtha.2023.05.023
M3 - Article
C2 - 37263381
SN - 1538-7933
VL - 21
SP - 2873
EP - 2883
JO - Journal of thrombosis and haemostasis : JTH
JF - Journal of thrombosis and haemostasis : JTH
IS - 10
ER -