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ACP: Not all patients need imaging for suspected PE

September 28, 2015

1. ACP: Doctors should stratify patients with suspected pulmonary embolism to determine diagnostic strategy

Overuse of computed tomography and D-dimer testing may not improve care and lead to patient harm and unnecessary expense
Free policy paper: http://www.annals.org/article.aspx?doi=10.7326/M14-1772
URL goes live when the embargo lifts

When evaluating patients with suspected acute pulmonary embolism (PE), physicians should stratify patients into groups for whom different diagnostic strategies are appropriate, the American College of Physicians (ACP) advises in a new paper published today in Annals of Internal Medicine.

PE is a sudden blockage in a lung artery. The cause is usually a blood clot in the leg called a deep vein thrombosis that breaks loose and travels through the bloodstream to the lung. Computed tomography (CT) is increasingly used to evaluate patients with suspected PE. However, there is no evidence to suggest that CT improves outcomes in such patients, and its use is associated with risks and expense. ACP's advice is designed to help physicians identify patients for whom testing, including imaging, is needed and for whom it is not.

In patients who have a low pre-test probability of PE, physicians should apply the PERC (Pulmonary Embolism Rule-Out Criteria) rule. Physicians should not obtain D-dimer tests or imaging studies in patients with a low pre-test probability of PE and who meet all eight PERC. Patients who have an intermediate pre-test probability of PE or patients with low pre-test probability of PE who do not meet all PERC should have a high sensitivity D-dimer test as the initial step in diagnosis, but no imaging. Patients with high pre-test probability of PE should obtain imaging with CT pulmonary angiography. Physicians should reserve V/Q scans for patients who have a contraindication for CT pulmonary angiography or if CT pulmonary angiography is not available. Physicians should avoid obtaining a D-dimer measurement in patients with a high pre-test probability of PE.

Note: For an embargoed PDF, please contact Angela Collom. To speak with someone from the American College of Physicians, please contact Steve Majewski at SMajewski@mail.acponline.org or 215-351-2514.




2. U.S. cervical cancer screening practices show room for improvement
Abstract: http://www.annals.org/article.aspx?doi=10.7326/M15-0420
URL goes live when the embargo lifts

An analysis published in Annals of Internal Medicine shows that current U.S. cervical cancer screening practices are inefficient with respect to health benefits and costs, due to noncompliance with recommended guidelines. Additional investments in interventions may be needed to improve screening programs.

Cytology-based screening has led to substantial declines in cervical cancer incidence and mortality, yet screening practices vary widely. Inefficiencies in screening lead to increased economic burden and disease incidence, especially among underserved populations. Researchers created mathematical models to compare reductions in lifetime cervical cancer risks, quality-adjusted life-years, and costs using current cervical cancer screening practices to the same outcomes using guideline-based screening intervals (every 3 years), HPV triage testing, diagnostic referrals, and precancer treatment referrals.

In terms of cost-effectiveness, current screening practice remained inefficient in all simulations conducted, implying that although guidelines-based strategies are more costly, the gains in health are also relatively greater. The added health benefit of improving compliance with guidelines, especially the 3-year interval for cytologic screening and diagnostic follow-up, may justify additional investments in interventions to improve U.S. cervical cancer screening practice.

Note: For an embargoed PDF, please Cara Graeff. The lead author, Dr. Jane Kim, can be reached through Todd Datz at tdatz@hsph.harvard.edu or 617-432-8413.




3. Two evidence reviews assess behavioral interventions for type 1 and type 2 diabetes

According to two systematic evidence reviews published in Annals of Internal Medicine, behavioral interventions offer limited improvements in glycemic control for patients with type 1 and type 2 diabetes. Such interventions did not seem to affect other health outcomes.

Type 1 diabetes
Abstract: http://www.annals.org/article.aspx?doi=10.7326/M15-1399

Type 1 diabetes is one of the most common chronic diseases in childhood and adolescents and is increasing in prevalence in the U.S. Intensive glycemic control has been proven to prevent diabetes-related health complications and death. Other factors, such as intensive lowering of blood pressure and diabetes-related stress management seem to improve outcomes, as well. Some data suggest that behavioral approaches for self-management programs benefit individuals with type 1 diabetes.

Researchers conducted a systematic review and meta-analysis of published research to determine the effects of behavioral programs for patients with type 1 diabetes on behavioral, clinical, and health outcomes and to investigate factors that might moderate the effect of such programs. They found that behavioral programs for type 1 diabetes offer some benefit for glycemic control, at least at short-term follow-up. The current evidence does not support encouraging patients with type 1 diabetes to participate in behavioral programs to improve outcomes except for glycemic control.

Type 2 diabetes
Abstract: http://www.annals.org/article.aspx?doi=10.7326/M15-1400

More than 29 million Americans suffer from type 2 diabetes. Tight glycemic control is important for reducing microvascular complications, as is management of body weight, blood pressure, and cholesterol levels. As such, patients with type 2 diabetes are advised to adhere to multiple self-care behaviors, including healthy eating, being active, taking medications, and healthy coping. Evidence suggests that behavioral interventions can help patients stick to their programs and achieve better health outcomes.

Researchers reviewed published evidence to identify factors that could improve the effectiveness of behavioral programs for adults with type 2 diabetes. They found that more intensive programs were more effective and worked better for patients with suboptimal glycemic control than for those with good control. Self-management education programs with 10 or fewer hours of contact with delivery personnel provided little benefit.

Note: For an embargoed PDF, please contact Angela Collom. The lead author of both reviews, Ms. Jennifer Pillay, can be reached through Michael Brown at mjbrown1@ualberta.ca or 780-492-9407.
-end-
Also in this issue:

Right-to-Try Laws: Hope, Hype, and Unintended Consequences
Alison Bateman-House, PhD, MPH, MA; Laura Kimberly, MSW, MBE; Barbara Redman, PhD, MBE; Nancy Dubler, LLB; and Arthur Caplan, PhD

Ideas and Opinions http://www.annals.org/article.aspx?doi=10.7326/M15-0148

Content, Consistency, and Quality of Black Box Warnings: Time for a Change
Tarig Elraiyah, MBBS, MSc; Michael R. Gionfriddo, PharmD; Victor M. Montori, MD, MSc; and Mohammad Hassan Murad, MD, MPH

Ideas and Opinions http://www.annals.org/article.aspx?doi=10.7326/M15-1097

American College of Physicians

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