Comparative diagnostic accuracy of pre-test clinical probability scores for the risk stratification of patients with suspected pulmonary embolism: a systematic review and Bayesian network meta-analysis
Abstract Background The primary evaluation of pulmonary embolism (PE) is complicated by the presence of various pre-test clinical probability scores (pCPS) with different cut-offs, all equally recommended by guidelines. This lack of consensus has led to practice variability, unnecessary imaging, and...
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2025-04-01
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| Online Access: | https://doi.org/10.1186/s12890-025-03637-6 |
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| author | Ali Etemadi Mohammadmobin Hosseini Hamed Rafiee Amir Mahboubi Tara Mahmoodi Toshiki Kuno Yaser Jenab Claire E. Raphael Wilbert S. Aronow Kaveh Hosseini Jay Giri |
| author_facet | Ali Etemadi Mohammadmobin Hosseini Hamed Rafiee Amir Mahboubi Tara Mahmoodi Toshiki Kuno Yaser Jenab Claire E. Raphael Wilbert S. Aronow Kaveh Hosseini Jay Giri |
| author_sort | Ali Etemadi |
| collection | DOAJ |
| description | Abstract Background The primary evaluation of pulmonary embolism (PE) is complicated by the presence of various pre-test clinical probability scores (pCPS) with different cut-offs, all equally recommended by guidelines. This lack of consensus has led to practice variability, unnecessary imaging, and worse patient outcomes. We aim to provide more definitive insights through a holistic comparison of available pCPS. Methods PubMed, Embase and Web of Science, and Google Scholar were searched for studies evaluating pCPS in patients clinically suspected of PE until June 2023. Risk of bias was evaluated using QUADAS-2. Included pCPS were evaluated based on their diagnostic accuracy in: (1) Ruling-out PE (2) Utilization of imaging, and (3) Differentiating between patients needing d-dimer from imaging. Diagnostic test accuracy indices were synthesized using beta-binomial Bayesian methods. Results Forty studies (37,027 patients) were included in the meta-analysis. Three-tier revised Geneva (RG) and three-tier Wells performed similarly in ruling-out PE (negative likelihood ratio (LR-) [95% credible interval (CI)]: 0·39[0·27–0·58] vs 0·34[0·25–0·45]). However, RG performed better in utilization of imaging (LR + : 6·65[3·75–10·56] vs 5·59[3·7–8·37], p < 0.001) and differentiating between patients needing d-dimer vs imaging (diagnostic odds ratio (DOR): 8·03[4·35–14·1] vs. 7·4[4·65–11·84], p < 0.001). The two-tier Wells score underperformed in all aspects (LR-: 0·56[0·45–0·68], LR + : 2·43[1·81–3·07], DOR: 4·41[2·81–6·43]). PERC demonstrated a reliable point estimate for ruling out PE, albeit with a wide CI (LR-: 0·36[0·17–0·78]). Conclusions RG outperforms other pCPS for primary evaluation of suspected PE. While the difference is not large, RG's independence from subjective items supports its recommendation over three-tier Wells. Two-tier Wells underperforms significantly compared to the rest of pCPS. PERC shows considerable promise for minimizing unnecessary D-dimer testing in crowded emergency departments; however, more evidence is needed before its definitive recommendation. Protocol registration PROSPERO (CRD42023464118). |
| format | Article |
| id | doaj-art-1bec4ffc63444172a79cd8e41c6d7231 |
| institution | DOAJ |
| issn | 1471-2466 |
| language | English |
| publishDate | 2025-04-01 |
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| series | BMC Pulmonary Medicine |
| spelling | doaj-art-1bec4ffc63444172a79cd8e41c6d72312025-08-20T03:06:48ZengBMCBMC Pulmonary Medicine1471-24662025-04-0125111010.1186/s12890-025-03637-6Comparative diagnostic accuracy of pre-test clinical probability scores for the risk stratification of patients with suspected pulmonary embolism: a systematic review and Bayesian network meta-analysisAli Etemadi0Mohammadmobin Hosseini1Hamed Rafiee2Amir Mahboubi3Tara Mahmoodi4Toshiki Kuno5Yaser Jenab6Claire E. Raphael7Wilbert S. Aronow8Kaveh Hosseini9Jay Giri10Tehran Heart Center, Cardiovascular Diseases Research Institute, Tehran University of Medical SciencesTehran Heart Center, Cardiovascular Diseases Research Institute, Tehran University of Medical SciencesTehran Heart Center, Cardiovascular Diseases Research Institute, Tehran University of Medical SciencesTehran Heart Center, Cardiovascular Diseases Research Institute, Tehran University of Medical SciencesTehran Heart Center, Cardiovascular Diseases Research Institute, Tehran University of Medical SciencesCardiology Division, Massachusetts General Hospital, Harvard Medical SchoolTehran Heart Center, Cardiovascular Diseases Research Institute, Tehran University of Medical SciencesDepartment of Cardiovascular Medicine, Mayo Clinic College of MedicineDepartment of Cardiology, Westchester Medical Center, New York Medical CollegeTehran Heart Center, Cardiovascular Diseases Research Institute, Tehran University of Medical SciencesPerelman School of Medicine, Cardiovascular Medicine Division, University of PennsylvaniaAbstract Background The primary evaluation of pulmonary embolism (PE) is complicated by the presence of various pre-test clinical probability scores (pCPS) with different cut-offs, all equally recommended by guidelines. This lack of consensus has led to practice variability, unnecessary imaging, and worse patient outcomes. We aim to provide more definitive insights through a holistic comparison of available pCPS. Methods PubMed, Embase and Web of Science, and Google Scholar were searched for studies evaluating pCPS in patients clinically suspected of PE until June 2023. Risk of bias was evaluated using QUADAS-2. Included pCPS were evaluated based on their diagnostic accuracy in: (1) Ruling-out PE (2) Utilization of imaging, and (3) Differentiating between patients needing d-dimer from imaging. Diagnostic test accuracy indices were synthesized using beta-binomial Bayesian methods. Results Forty studies (37,027 patients) were included in the meta-analysis. Three-tier revised Geneva (RG) and three-tier Wells performed similarly in ruling-out PE (negative likelihood ratio (LR-) [95% credible interval (CI)]: 0·39[0·27–0·58] vs 0·34[0·25–0·45]). However, RG performed better in utilization of imaging (LR + : 6·65[3·75–10·56] vs 5·59[3·7–8·37], p < 0.001) and differentiating between patients needing d-dimer vs imaging (diagnostic odds ratio (DOR): 8·03[4·35–14·1] vs. 7·4[4·65–11·84], p < 0.001). The two-tier Wells score underperformed in all aspects (LR-: 0·56[0·45–0·68], LR + : 2·43[1·81–3·07], DOR: 4·41[2·81–6·43]). PERC demonstrated a reliable point estimate for ruling out PE, albeit with a wide CI (LR-: 0·36[0·17–0·78]). Conclusions RG outperforms other pCPS for primary evaluation of suspected PE. While the difference is not large, RG's independence from subjective items supports its recommendation over three-tier Wells. Two-tier Wells underperforms significantly compared to the rest of pCPS. PERC shows considerable promise for minimizing unnecessary D-dimer testing in crowded emergency departments; however, more evidence is needed before its definitive recommendation. Protocol registration PROSPERO (CRD42023464118).https://doi.org/10.1186/s12890-025-03637-6Pulmonary EmbolismRisk AssessmentPredictive Value of TestsClinical Decision Support System |
| spellingShingle | Ali Etemadi Mohammadmobin Hosseini Hamed Rafiee Amir Mahboubi Tara Mahmoodi Toshiki Kuno Yaser Jenab Claire E. Raphael Wilbert S. Aronow Kaveh Hosseini Jay Giri Comparative diagnostic accuracy of pre-test clinical probability scores for the risk stratification of patients with suspected pulmonary embolism: a systematic review and Bayesian network meta-analysis BMC Pulmonary Medicine Pulmonary Embolism Risk Assessment Predictive Value of Tests Clinical Decision Support System |
| title | Comparative diagnostic accuracy of pre-test clinical probability scores for the risk stratification of patients with suspected pulmonary embolism: a systematic review and Bayesian network meta-analysis |
| title_full | Comparative diagnostic accuracy of pre-test clinical probability scores for the risk stratification of patients with suspected pulmonary embolism: a systematic review and Bayesian network meta-analysis |
| title_fullStr | Comparative diagnostic accuracy of pre-test clinical probability scores for the risk stratification of patients with suspected pulmonary embolism: a systematic review and Bayesian network meta-analysis |
| title_full_unstemmed | Comparative diagnostic accuracy of pre-test clinical probability scores for the risk stratification of patients with suspected pulmonary embolism: a systematic review and Bayesian network meta-analysis |
| title_short | Comparative diagnostic accuracy of pre-test clinical probability scores for the risk stratification of patients with suspected pulmonary embolism: a systematic review and Bayesian network meta-analysis |
| title_sort | comparative diagnostic accuracy of pre test clinical probability scores for the risk stratification of patients with suspected pulmonary embolism a systematic review and bayesian network meta analysis |
| topic | Pulmonary Embolism Risk Assessment Predictive Value of Tests Clinical Decision Support System |
| url | https://doi.org/10.1186/s12890-025-03637-6 |
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