CHANGING PRACTICE PATTERNS IN THE WORK-UP OF PULMONARY-EMBOLISM

Study objective: While the ''gold standard'' for diagnosis of pulmonar y embolism remains selective pulmonary angiography and its sensitivity and specificity are very high, it is not frequently used. The Prospec tive Investigation of Pulmonary Embolism Diagnosis (PIOPED) clinical t rial results confirmed the low mortality and morbidity of pulmonary an giogram and the need for further evaluation of patients with ''low'' a nd ''intermediate'' probability ventilation/perfusion scans. We wanted to determine whether physician behavior changed from 1988 to 1991. De sign: Retrospective review of inpatients having a ventilation/perfusio n scan for suspected pulmonary embolism. The official reading of the v entilation/perfusion scans, venous leg sonograms with Doppler, contras t leg venograms, and pulmonary angiograms were recorded as well as the final diagnosis and treatment. Setting: A large city hospital-The New York Hospital-Cornell Medical Center, New York. Patients: All inpatie nts who had a ventilation perfusion scan in 1988 and all inpatients wh o had the procedure in 1991. Intervention: None. Results: The percenta ges of patients in each ventilation/perfusion scan category were simil ar in 1988 and 1991 as was the percentage of those who underwent antic oagulation therapy. Significantly more sonograms, however, were perfor med in 1991 along with fewer angiograms and venograms without any sign ificant change in the overall cost. Conclusions: In 1991, additional d iagnostic tests were performed after a low or intermediate ventilation /perfusion scan, but the percentage of patients who underwent anticoag ulation did not change from 1988. This suggests that better diagnostic screening approaches with more explicit guidelines need to be develop ed that take into account the local disease prevalance and hospital di agnostic and practice patterns.