Multicenter Evaluation of the YEARS Criteria in Emergency Department Patients Evaluated for Pulmonary Embolism

Christopher Kabrhel, Astrid Van Hylckama Vlieg, Alona Muzikanski, Adam Singer, Gregory J. Fermann, Samuel Francis, Alex Limkakeng, Anna Marie Chang, Nicholas Giordano, Blair Parry

Research output: Contribution to journalArticle

6 Citations (Scopus)

Abstract

Background: It may be possible to safely rule out pulmonary embolism (PE) in patients with low pretest probability (PTP) using a higher than standard D-dimer threshold. The YEARS criteria, which include three questions from the Wells PE score to identify low-PTP patients and a variable D-dimer threshold, was recently shown to decrease the need for imaging to rule out PE by 14% in a multicenter study in the Netherlands. However, the YEARS approach has not been studied in the United States. Methods: This study was a prospective, observational study of consecutive adult patients evaluated for PE in 17 U.S. emergency departments. Prior to diagnostic testing, we collected the YEARS criteria: “Does the patient have clinical signs or symptoms of DVT?” “Does the patient have hemoptysis?” “Are alternative diagnoses less likely than PE?” with YEARS (+) being any “yes” response. A negative D-dimer was <1000 mg/dL for YEARS (–) patients and <500 mg/dL for YEARS (+) patients. We calculated test characteristics and used Fisher's exact test to compare proportions of patients who would have been referred for imaging and patients who would have had PE “missed.”. Results: Of 1,789 patients, 84 (4%) had PE, 1,134 (63%) were female, 1,038 (58%) were white, and mean (±SD) age was 48 (±16) years. Using the standard D-dimer threshold, 940 (53%) would not have had imaging, with two (0.2%, 95% confidence interval [CI] = 0.02%–0.60%) missed PE. Using YEARS adjustment, 1,204 (67%, 95% CI = 65%–69%) would not have been referred for imaging, with six (0.5%, 95% CI = 0.18%–1.1%) missed PE, and using “alternative diagnoses less likely than PE” adjustment, 1,237 (69%, 95% CI = 67%–71%) would not have had imaging with six (0.49%, 95% CI = 0.18%–1.05%) missed PE. Sensitivity was 97.6% (95% CI = 91.7%–99.7%) for the standard threshold and 92.9% (95% CI = 85%–97%) for both adjusted thresholds. Negative predictive value (NPV) was nearly 100% for all approaches. Conclusions: D-dimer adjustment based on PTP may result in a reduced need for imaging to evaluate possible PE, with some additional missed PE but no decrease in NPV.

Original languageEnglish (US)
Pages (from-to)987-994
Number of pages8
JournalAcademic Emergency Medicine
Volume25
Issue number9
DOIs
StatePublished - Sep 1 2018
Externally publishedYes

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Pulmonary Embolism
Hospital Emergency Service
Confidence Intervals
Hemoptysis
Netherlands
Multicenter Studies
Signs and Symptoms
Observational Studies
fibrin fragment D
Prospective Studies

ASJC Scopus subject areas

  • Emergency Medicine

Cite this

Kabrhel, C., Van Hylckama Vlieg, A., Muzikanski, A., Singer, A., Fermann, G. J., Francis, S., ... Parry, B. (2018). Multicenter Evaluation of the YEARS Criteria in Emergency Department Patients Evaluated for Pulmonary Embolism. Academic Emergency Medicine, 25(9), 987-994. https://doi.org/10.1111/acem.13417

Multicenter Evaluation of the YEARS Criteria in Emergency Department Patients Evaluated for Pulmonary Embolism. / Kabrhel, Christopher; Van Hylckama Vlieg, Astrid; Muzikanski, Alona; Singer, Adam; Fermann, Gregory J.; Francis, Samuel; Limkakeng, Alex; Chang, Anna Marie; Giordano, Nicholas; Parry, Blair.

In: Academic Emergency Medicine, Vol. 25, No. 9, 01.09.2018, p. 987-994.

Research output: Contribution to journalArticle

Kabrhel, C, Van Hylckama Vlieg, A, Muzikanski, A, Singer, A, Fermann, GJ, Francis, S, Limkakeng, A, Chang, AM, Giordano, N & Parry, B 2018, 'Multicenter Evaluation of the YEARS Criteria in Emergency Department Patients Evaluated for Pulmonary Embolism', Academic Emergency Medicine, vol. 25, no. 9, pp. 987-994. https://doi.org/10.1111/acem.13417
Kabrhel C, Van Hylckama Vlieg A, Muzikanski A, Singer A, Fermann GJ, Francis S et al. Multicenter Evaluation of the YEARS Criteria in Emergency Department Patients Evaluated for Pulmonary Embolism. Academic Emergency Medicine. 2018 Sep 1;25(9):987-994. https://doi.org/10.1111/acem.13417
Kabrhel, Christopher ; Van Hylckama Vlieg, Astrid ; Muzikanski, Alona ; Singer, Adam ; Fermann, Gregory J. ; Francis, Samuel ; Limkakeng, Alex ; Chang, Anna Marie ; Giordano, Nicholas ; Parry, Blair. / Multicenter Evaluation of the YEARS Criteria in Emergency Department Patients Evaluated for Pulmonary Embolism. In: Academic Emergency Medicine. 2018 ; Vol. 25, No. 9. pp. 987-994.
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abstract = "Background: It may be possible to safely rule out pulmonary embolism (PE) in patients with low pretest probability (PTP) using a higher than standard D-dimer threshold. The YEARS criteria, which include three questions from the Wells PE score to identify low-PTP patients and a variable D-dimer threshold, was recently shown to decrease the need for imaging to rule out PE by 14{\%} in a multicenter study in the Netherlands. However, the YEARS approach has not been studied in the United States. Methods: This study was a prospective, observational study of consecutive adult patients evaluated for PE in 17 U.S. emergency departments. Prior to diagnostic testing, we collected the YEARS criteria: “Does the patient have clinical signs or symptoms of DVT?” “Does the patient have hemoptysis?” “Are alternative diagnoses less likely than PE?” with YEARS (+) being any “yes” response. A negative D-dimer was <1000 mg/dL for YEARS (–) patients and <500 mg/dL for YEARS (+) patients. We calculated test characteristics and used Fisher's exact test to compare proportions of patients who would have been referred for imaging and patients who would have had PE “missed.”. Results: Of 1,789 patients, 84 (4{\%}) had PE, 1,134 (63{\%}) were female, 1,038 (58{\%}) were white, and mean (±SD) age was 48 (±16) years. Using the standard D-dimer threshold, 940 (53{\%}) would not have had imaging, with two (0.2{\%}, 95{\%} confidence interval [CI] = 0.02{\%}–0.60{\%}) missed PE. Using YEARS adjustment, 1,204 (67{\%}, 95{\%} CI = 65{\%}–69{\%}) would not have been referred for imaging, with six (0.5{\%}, 95{\%} CI = 0.18{\%}–1.1{\%}) missed PE, and using “alternative diagnoses less likely than PE” adjustment, 1,237 (69{\%}, 95{\%} CI = 67{\%}–71{\%}) would not have had imaging with six (0.49{\%}, 95{\%} CI = 0.18{\%}–1.05{\%}) missed PE. Sensitivity was 97.6{\%} (95{\%} CI = 91.7{\%}–99.7{\%}) for the standard threshold and 92.9{\%} (95{\%} CI = 85{\%}–97{\%}) for both adjusted thresholds. Negative predictive value (NPV) was nearly 100{\%} for all approaches. Conclusions: D-dimer adjustment based on PTP may result in a reduced need for imaging to evaluate possible PE, with some additional missed PE but no decrease in NPV.",
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AU - Van Hylckama Vlieg, Astrid

AU - Muzikanski, Alona

AU - Singer, Adam

AU - Fermann, Gregory J.

AU - Francis, Samuel

AU - Limkakeng, Alex

AU - Chang, Anna Marie

AU - Giordano, Nicholas

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N2 - Background: It may be possible to safely rule out pulmonary embolism (PE) in patients with low pretest probability (PTP) using a higher than standard D-dimer threshold. The YEARS criteria, which include three questions from the Wells PE score to identify low-PTP patients and a variable D-dimer threshold, was recently shown to decrease the need for imaging to rule out PE by 14% in a multicenter study in the Netherlands. However, the YEARS approach has not been studied in the United States. Methods: This study was a prospective, observational study of consecutive adult patients evaluated for PE in 17 U.S. emergency departments. Prior to diagnostic testing, we collected the YEARS criteria: “Does the patient have clinical signs or symptoms of DVT?” “Does the patient have hemoptysis?” “Are alternative diagnoses less likely than PE?” with YEARS (+) being any “yes” response. A negative D-dimer was <1000 mg/dL for YEARS (–) patients and <500 mg/dL for YEARS (+) patients. We calculated test characteristics and used Fisher's exact test to compare proportions of patients who would have been referred for imaging and patients who would have had PE “missed.”. Results: Of 1,789 patients, 84 (4%) had PE, 1,134 (63%) were female, 1,038 (58%) were white, and mean (±SD) age was 48 (±16) years. Using the standard D-dimer threshold, 940 (53%) would not have had imaging, with two (0.2%, 95% confidence interval [CI] = 0.02%–0.60%) missed PE. Using YEARS adjustment, 1,204 (67%, 95% CI = 65%–69%) would not have been referred for imaging, with six (0.5%, 95% CI = 0.18%–1.1%) missed PE, and using “alternative diagnoses less likely than PE” adjustment, 1,237 (69%, 95% CI = 67%–71%) would not have had imaging with six (0.49%, 95% CI = 0.18%–1.05%) missed PE. Sensitivity was 97.6% (95% CI = 91.7%–99.7%) for the standard threshold and 92.9% (95% CI = 85%–97%) for both adjusted thresholds. Negative predictive value (NPV) was nearly 100% for all approaches. Conclusions: D-dimer adjustment based on PTP may result in a reduced need for imaging to evaluate possible PE, with some additional missed PE but no decrease in NPV.

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