YEARS clinical decision rule for diagnosing pulmonary embolism: a prospective diagnostic cohort follow-up study in primary care
Objectives The Wells rule is often used in primary care to rule out pulmonary embolism (PE), but its efficiency is low as many referred patients do not have PE. In this study, we evaluated in primary care an alternative and potentially more efficient diagnostic strategy—the YEARS algorithm; a simpli...
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BMJ Publishing Group
2025-02-01
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| Series: | BMJ Open |
| Online Access: | https://bmjopen.bmj.com/content/15/2/e091543.full |
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| author | Frans H Rutten Menno V Huisman Jeanet Blom Rosanne van Maanen Frederikus A Klok Geert-Jan Geersing Karel Moons Hannah M la Roi-Teeuw Melchior Nierman Tuur Egbers |
| author_facet | Frans H Rutten Menno V Huisman Jeanet Blom Rosanne van Maanen Frederikus A Klok Geert-Jan Geersing Karel Moons Hannah M la Roi-Teeuw Melchior Nierman Tuur Egbers |
| author_sort | Frans H Rutten |
| collection | DOAJ |
| description | Objectives The Wells rule is often used in primary care to rule out pulmonary embolism (PE), but its efficiency is low as many referred patients do not have PE. In this study, we evaluated in primary care an alternative and potentially more efficient diagnostic strategy—the YEARS algorithm; a simplified three-item version of the Wells rule combined with a pretest probability adjusted D-dimer interpretation.Design In this comprehensive prospective diagnostic validation study, primary care patients suspected of PE were enrolled by their general practitioner. All three YEARS items were collected in addition to D-dimer results, and patients were followed for 3 months to establish the final diagnosis.Setting Primary care in the Netherlands.Participants 753 patients with suspected acute PE were included. Five patients (0.7%) were lost to follow-up.Main outcome measures Failure rate (number of PE cases among patients classified by the algorithm as ‘PE ruled-out’) and efficiency (fraction of patients classified as ‘PE probable/further imaging needed’).Results Prevalence of PE was 5.5% (41/748 patients). In total, 603 patients were classified as ‘PE ruled-out’ by the YEARS algorithm (532 with zero YEARS items and a D-dimer<1000 ng/mL and 71 with≥1 positive YEARS item and a D-dimer<500 ng/mL), resulting in an efficiency of 80.6% (603/748 patients, 95% CI 77.6% to 83.4%). Of these patients, three patients had a diagnosis of non-fatal PE during 3 months follow-up, all three with zero YEARS items and D-dimer between 500 and 1000 ng/mL, resulting in an overall diagnostic failure rate of 0.50% (3/603 patients, 95% CI 0.13% to 1.57%). In the patients categorised as ‘imaging needed’ (n=145), a total of 38 (26.2%) were indeed diagnosed with PE.Conclusions Our study suggests that acute PE can be safely ruled out in 80% of patients by the YEARS algorithm in a primary care setting, while only 20% of patients required referral to hospital care for imaging tests. In those classified as ‘imaging needed’, PE was present in about one in every four patients, demonstrating a high detection proportion. |
| format | Article |
| id | doaj-art-c3e8fe99022f4fefb9e9300ded282554 |
| institution | Kabale University |
| issn | 2044-6055 |
| language | English |
| publishDate | 2025-02-01 |
| publisher | BMJ Publishing Group |
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| series | BMJ Open |
| spelling | doaj-art-c3e8fe99022f4fefb9e9300ded2825542025-02-07T03:30:11ZengBMJ Publishing GroupBMJ Open2044-60552025-02-0115210.1136/bmjopen-2024-091543YEARS clinical decision rule for diagnosing pulmonary embolism: a prospective diagnostic cohort follow-up study in primary careFrans H Rutten0Menno V Huisman1Jeanet Blom2Rosanne van Maanen3Frederikus A Klok4Geert-Jan Geersing5Karel Moons6Hannah M la Roi-Teeuw7Melchior Nierman8Tuur Egbers91 Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands3 Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands6 Leiden University Medical Center, Leiden, The Netherlands1 Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands3 Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands5 Department of General Practice and Nursing Science, Utrecht University, Utrecht, The Netherlands7 Department of Epidemiology, Julius Center for Health Sciences and Primary Care, Utrecht, The Netherlands1 Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands2 Department of Thrombosis, Atalmedial Medical Diagnostics Centers, Amsterdam, The Netherlands5 Department of General Practice and Nursing Science, Utrecht University, Utrecht, The NetherlandsObjectives The Wells rule is often used in primary care to rule out pulmonary embolism (PE), but its efficiency is low as many referred patients do not have PE. In this study, we evaluated in primary care an alternative and potentially more efficient diagnostic strategy—the YEARS algorithm; a simplified three-item version of the Wells rule combined with a pretest probability adjusted D-dimer interpretation.Design In this comprehensive prospective diagnostic validation study, primary care patients suspected of PE were enrolled by their general practitioner. All three YEARS items were collected in addition to D-dimer results, and patients were followed for 3 months to establish the final diagnosis.Setting Primary care in the Netherlands.Participants 753 patients with suspected acute PE were included. Five patients (0.7%) were lost to follow-up.Main outcome measures Failure rate (number of PE cases among patients classified by the algorithm as ‘PE ruled-out’) and efficiency (fraction of patients classified as ‘PE probable/further imaging needed’).Results Prevalence of PE was 5.5% (41/748 patients). In total, 603 patients were classified as ‘PE ruled-out’ by the YEARS algorithm (532 with zero YEARS items and a D-dimer<1000 ng/mL and 71 with≥1 positive YEARS item and a D-dimer<500 ng/mL), resulting in an efficiency of 80.6% (603/748 patients, 95% CI 77.6% to 83.4%). Of these patients, three patients had a diagnosis of non-fatal PE during 3 months follow-up, all three with zero YEARS items and D-dimer between 500 and 1000 ng/mL, resulting in an overall diagnostic failure rate of 0.50% (3/603 patients, 95% CI 0.13% to 1.57%). In the patients categorised as ‘imaging needed’ (n=145), a total of 38 (26.2%) were indeed diagnosed with PE.Conclusions Our study suggests that acute PE can be safely ruled out in 80% of patients by the YEARS algorithm in a primary care setting, while only 20% of patients required referral to hospital care for imaging tests. In those classified as ‘imaging needed’, PE was present in about one in every four patients, demonstrating a high detection proportion.https://bmjopen.bmj.com/content/15/2/e091543.full |
| spellingShingle | Frans H Rutten Menno V Huisman Jeanet Blom Rosanne van Maanen Frederikus A Klok Geert-Jan Geersing Karel Moons Hannah M la Roi-Teeuw Melchior Nierman Tuur Egbers YEARS clinical decision rule for diagnosing pulmonary embolism: a prospective diagnostic cohort follow-up study in primary care BMJ Open |
| title | YEARS clinical decision rule for diagnosing pulmonary embolism: a prospective diagnostic cohort follow-up study in primary care |
| title_full | YEARS clinical decision rule for diagnosing pulmonary embolism: a prospective diagnostic cohort follow-up study in primary care |
| title_fullStr | YEARS clinical decision rule for diagnosing pulmonary embolism: a prospective diagnostic cohort follow-up study in primary care |
| title_full_unstemmed | YEARS clinical decision rule for diagnosing pulmonary embolism: a prospective diagnostic cohort follow-up study in primary care |
| title_short | YEARS clinical decision rule for diagnosing pulmonary embolism: a prospective diagnostic cohort follow-up study in primary care |
| title_sort | years clinical decision rule for diagnosing pulmonary embolism a prospective diagnostic cohort follow up study in primary care |
| url | https://bmjopen.bmj.com/content/15/2/e091543.full |
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