53 Analyzing the Components of the Wells' Score for Pulmonary Embolus Can Strengthen Unstructured Physician Gestalt

Abstract

In determining pretest probability for pulmonary embolus (PE) in emergency department (ED) patients, recent studies have shown physician gestalt to be similar or superior to structured clinical decision instruments. Physician gestalt is unique to each practicing emergency physician, developed through clinical practice, knowledge, and experience. Physician trainees often lack that prior clinical experience to develop a gestalt. This study sought to find the predictive value of the individual components of the Wells’ PE score to better delineate the findings that are more predictive of PE, aiding in development of individual gestalt. We conducted a multinational, prospective observational study of adult patients presenting to EDs with suspected PE. Wells’ PE scores were calculated by the treating physicians. D-Dimer assays were performed using a single assay (INNOVANCE D-Dimer, Siemens). Confirmatory imaging (CT angiography of the chest or ventilation/perfusion scan) was obtained at the discretion of the treating physician. Patients were prospectively followed for clinical outcomes by record review and phone follow-up. We created a multivariable logistic regression model to assess associations between the individual elements of the Wells’ PE scores. We enrolled 1,834 patients with suspected PE and a non-high pretest probability, with a mean Wells’ PE score of 1.8 (SD 1.8). 63.1% were female, 36.9% were male. 55.9% were younger than 50 years old, 44.1% were 50 or older. 58.9% were Caucasian, 30.2% were African American, 7.9% were Hispanic, 1% were Asian, and 2% were other ethnicities. 28.4% were tachycardic, 7.1% had active cancer, and 10% had recent immobilization or surgery in the past 4 weeks. 9.4% had a prior history of VTE. Overall 5.5% (101/1834) were diagnosed with PE. An additional 7 patients were diagnosed with subsegmental PE. The individual components of the Wells’ Score for PE are listed below in Table 1. In this large patient cohort evaluated for PE, PE being the #1 or equally likely diagnosis, prior history of VTE, and recent immobilization or surgery in the previous 4 weeks had the greatest predictive value for subsequent diagnosis of PE. Signs and symptoms of a DVT, malignancy, heart rate greater than 100 bpm, and hemoptysis were less predictive of PE in analysis. Amongst the Wells’ score for PE criteria, it is physician’s gestalt that best predicts diagnosis of PE.Table 1Individual Components of the Wells' Score for PE with associated adjusted odds ratio and p-valueWells’ Score ComponentAdjusted OR (95% CI)p-valuePE is the #1 diagnosis or equally likely3.97 (2.52-6.25)<0.0001Previous DVT or PE3.40 (1.97-5.88)<0.0001Immobilization or surgery in the previous 4 weeks2.18 (1.23-3.84)0.0074Clinical signs and symptoms of DVT1.71 (0.84-3.47)0.14Malignancy (on treatment, treatement in last 6 months, or palliative)1.19 (0.59-2.41)0.63Heart rate greater than 100 bpm1.18 (0.72-1.93)0.50Hemoptysis0.57 (0.10-3.24)0.52 Open table in a new tab