Abstract
BackgroundStudies show the In-hospital Mortality for Pulmonary embolism using Claims daTa (IMPACT) rule can accurately identify pulmonary embolism (PE) patients at low-risk of early mortality in a retrospective setting using only claims for the index admission. We sought to externally validate IMPACT, Pulmonary Embolism Severity Index (PESI), simplified PESI (sPESI) and Hestia for predicting early mortality.MethodsWe identified consecutive adults admitted for objectively-confirmed PE between 10/21/2010 and 5/12/2015. Patients undergoing thrombolysis/embolectomy within 48 h were excluded. All-cause in-hospital and 30 day mortality (using available Social Security Death Index data through January 2014) were assessed and prognostic accuracies of IMPACT, PESI, sPESI and Hestia were determined.ResultsTwenty-one (2.6 %) of the 807 PE patients died before discharge. All rules classified 26.1–38.3 % of patients as low-risk for early mortality. Fatality among low-risk patients was 0 % (sPESI and Hestia), 0.4 % (IMPACT) and 0.6 % (PESI). IMPACT’s sensitivity was 95.2 % (95 % confidence interval [CI] = 74.1–99.8 %), and the sensitivities of clinical rules ranged from 91 (PESI)-100 % (sPESI and Hestia). Specificities of all rules ranged between 26.8 and 39.1 %. Of 573 consecutive patients in the 30 day mortality analysis, 33 (5.8 %) died. All rules classified 27.9–38.0 % of patients as low-risk, and fatality occurred in 0 (Hestia)-1.4 % (PESI) of low-risk patients. IMPACT’s sensitivity was 97.0 % (95%CI = 82.5–99.8 %), while sensitivities for clinical rules ranged from 91 (PESI)-100 % (Hestia). Specificities of rules ranged between 29.6 and 39.8 %.ConclusionIn this analysis, IMPACT identified low-risk PE patients with similar accuracy as clinical rules. While not intended for prospective clinical decision-making, IMPACT appears useful for identification of low-risk PE patient in retrospective claims-based studies.Electronic supplementary materialThe online version of this article (doi:10.1186/s12959-016-0081-5) contains supplementary material, which is available to authorized users.
Highlights
Studies show the In-hospital Mortality for Pulmonary embolism using Claims daTa (IMPACT) rule can accurately identify pulmonary embolism (PE) patients at low-risk of early mortality in a retrospective setting using only claims for the index admission
Guidelines suggest that patients with pulmonary embolism (PE) who are identified to have a low-risk of early post-PE all-cause mortality may be candidates for abbreviated hospital admission or outpatient treatment if appropriate follow-up can be arranged [1, 2]
Preparation of this study report was in accordance with the Transparent reporting of a multivariable prediction model for individual prognosis or diagnosis (TRIPOD) statement [12]
Summary
Studies show the In-hospital Mortality for Pulmonary embolism using Claims daTa (IMPACT) rule can accurately identify pulmonary embolism (PE) patients at low-risk of early mortality in a retrospective setting using only claims for the index admission. Guidelines suggest that patients with pulmonary embolism (PE) who are identified to have a low-risk of early post-PE all-cause mortality may be candidates for abbreviated hospital admission or outpatient treatment if appropriate follow-up can be arranged [1, 2]. A prior meta-analysis suggested at least one-third of acute PE patients could be classified as low-risk for early mortality according to clinical prediction rules [5] This same meta-analysis identified the Pulmonary Embolism Severity Index (PESI), simplified PESI (sPESI) and Hestia clinical prediction rules as having high sensitivities and negative predictive values (NPVs) for identifying low-risk PE patients. The utility of PESI, sPESI or Hestia for retrospective identification of low-risk patients with PE is limited
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