Risk stratifying emergency department patients with acute pulmonary embolism: Does the simplified Pulmonary Embolism Severity Index perform as well as the original?

Abstract Introduction The Pulmonary Embolism Severity Index (PESI) is a validated prognostic score to estimate the 30-day mortality of emergency department (ED) patients with acute pulmonary embolism (PE). A simplified version (sPESI) was derived but has not been as well studied in the U.S. We sough...

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Published in:	Thrombosis research Vol. 148; pp. 1 - 8
Main Authors:	Vinson, David R, Ballard, Dustin W, Mark, Dustin G, Huang, Jie, Reed, Mary E, Rauchwerger, Adina S, Wang, David H, Lin, James S, Kene, Mamata V, Pleshakov, Tamara S, Sax, Dana K, Sax, Jordan M, McLachlan, D. Ian, Yamin, Cyrus K, Swap, Clifford J, Iskin, Hilary R, Vemula, Ridhima, Fleming, Bethany S, Elms, Andrew R, Aujesky, Drahomir
Format:	Journal Article
Language:	English
Published:	United States Elsevier Ltd 01-12-2016
Subjects:	Adult Aged Aged, 80 and over Clinical prediction rule Decision Support Techniques Emergency Service, Hospital Female Hematology, Oncology and Palliative Medicine Hospitalization Humans Male Middle Aged Predictive Value of Tests Prognosis Pulmonary embolism Pulmonary Embolism - diagnosis Pulmonary Embolism - mortality Retrospective Studies Risk Assessment Risk Factors ROC Curve Severity of Illness Index S everity of illness index simplified Pulmonary Embolism Severity Index DVT CPT VTE sPESI International Classification of Disease P ulmonary embolism Kaiser Permanente pulmonary embolism ED management of acute pulmonary embolism P rognosis KP Current Procedural Terminology Pulmonary Embolism Severity Index ICD emergency department R isk assessment PESI MAPLE PE venous thromboembolism C linical prediction rule D ecision support techniques deep venous thrombosis Severity of illness index Prognosis Clinical prediction rule Pulmonary embolism Decision support techniques Risk assessment
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Summary:	Abstract Introduction The Pulmonary Embolism Severity Index (PESI) is a validated prognostic score to estimate the 30-day mortality of emergency department (ED) patients with acute pulmonary embolism (PE). A simplified version (sPESI) was derived but has not been as well studied in the U.S. We sought to validate both indices in a community hospital setting in the U.S. and compare their performance in predicting 30-day all-cause mortality and classification of cases into low-risk and higher-risk categories. Materials and methods This retrospective cohort study included adults with acute objectively confirmed PE from 1/2013 to 4/2015 across 21 community EDs. We evaluated the misclassification rate of the sPESI compared with PESI. We assessed accuracy of both indices with regard to 30-day mortality. Results Among 3 006 cases of acute PE, the 30-day all-cause mortality rate was 4.4%. The sPESI performed as well as the PESI in identifying low-risk patients: both had similar sensitivities, negative predictive values, and negative likelihood ratios. The sPESI, however, classified a smaller proportion of patients as low risk than the PESI (27.5% vs. 41.0%), but with similar low-risk mortality rates (< 1%). Compared with the PESI, the sPESI overclassified 443 low-risk patients (14.7%) as higher risk, yet their 30-day mortality was 0.7%. sPESI underclassified 100 higher-risk patients (3.3%) as low risk, who also had a low mortality rate (1.0%). Conclusions Both indices identified patients with PE who were at low risk for 30-day mortality. The sPESI, however, misclassified a significant number of low-mortality patients as higher risk, which could lead to unnecessary hospitalizations.
Bibliography:	ObjectType-Article-1 SourceType-Scholarly Journals-1 ObjectType-Feature-2 content type line 23
ISSN:	0049-3848 1879-2472
DOI:	10.1016/j.thromres.2016.09.023