Simplified Geneva Score Research Articles

Risk Assessment Models for Venous Thromboembolism in Medical Inpatients

Thromboprophylaxis is recommended for medical inpatients at risk of venous thromboembolism (VTE). Risk assessment models (RAMs) have been developed to stratify VTE risk, but a prospective head-to-head comparison of validated RAMs is lacking. To prospectively validate an easy-to-use RAM, the simplified Geneva score, and compare its prognostic performance with previously validated RAMs. This prospective cohort study was conducted from June 18, 2020, to January 4, 2022, with a 90-day follow-up. A total of 4205 consecutive adults admitted to the general internal medicine departments of 3 Swiss university hospitals for hospitalization for more than 24 hours due to acute illness were screened for eligibility; 1352 without therapeutic anticoagulation were included. At admission, items of 4 RAMs (ie, the simplified and original Geneva score, the Padua score, and the IMPROVE [International Medical Prevention Registry on Venous Thromboembolism] score) were collected. Patients were stratified into high and low VTE risk groups according to each RAM. Symptomatic VTE within 90 days. Of 1352 medical inpatients (median age, 67 years [IQR, 54-77 years]; 762 men [55.4%]), 28 (2.1%) experienced VTE. Based on the simplified Geneva score, 854 patients (63.2%) were classified as high risk, with a 90-day VTE risk of 2.6% (n = 22; 95% CI, 1.7%-3.9%), and 498 patients (36.8%) were classified as low risk, with a 90-day VTE risk of 1.2% (n = 6; 95% CI, 0.6%-2.6%). Sensitivity of the simplified Geneva score was 78.6% (95% CI, 60.5%-89.8%) and specificity was 37.2% (95% CI, 34.6%-39.8%); the positive likelihood ratio of the simplified Geneva score was 1.25 (95% CI, 1.03-1.52) and the negative likelihood ratio was 0.58 (95% CI, 0.28-1.18). In head-to-head comparisons, sensitivity was highest for the original Geneva score (82.1%; 95% CI, 64.4%-92.1%), while specificity was highest for the IMPROVE score (70.4%; 95% CI, 67.9%-72.8%). After adjusting the VTE risk for thromboprophylaxis use and site, there was no significant difference between the high-risk and low-risk groups based on the simplified Geneva score (subhazard ratio, 2.04 [95% CI, 0.83-5.05]; P = .12) and other RAMs. Discriminative performance was poor for all RAMs, with an area under the receiver operating characteristic curve ranging from 53.8% (95% CI, 51.1%-56.5%) for the original Geneva score to 58.1% (95% CI, 55.4%-60.7%) for the simplified Geneva score. This head-to-head comparison of validated RAMs found suboptimal accuracy and prognostic performance of the simplified Geneva score and other RAMs to predict hospital-acquired VTE in medical inpatients. Clinical usefulness of existing RAMs is questionable, highlighting the need for more accurate VTE prediction strategies.

P268 MANAGEMENT OF ACUTE PULMONARY EMBOLISM IN THE EMERGENCY ROOM IN ELDERLY: DOES ADHERENCE TO INTERNATIONAL GUIDELINES INCREASE IN THE MOST SERIOUS CASES?

Abstract Premises Pulmonary embolism is a pathology still characterized by high mortality. Some international studies have actually shown that adherence to guidelines is generally quite low in both primary and secondary care and ranges, depending on the studies, between 40 and 60%. Purpose of the Study see if and how, in the real life of an Emergency Department, adherence to the Guidelines varies according to the severity of the acute pulmonary embolism. We understood this severity as the presence of organ damage or massive pulmonary embolism. Methods Single–center retrospective observational study, on all geriatric patients (>75 y) who entered our ED, where they received a diagnosis of acute PE. Enrollment began in 2016 and ended in 2019. We collected data from medical history, physical examination, laboratory tests, imaging; we calculated the characteristic scores from the diagnostic / therapeutic algorithm, both for the risk of PE (Wells, Geneva and Years), and for the presentation of the risk of mortality at 30 days (sPESI). We therefore analyzed adherence to the guidelines in three decisional turning points: 1 Correct application of the decision scores examined, which classify the patient at low, intermediate or high risk of PE, calculated with Wells and simplified Geneva score; 2 Correct administration of therapy starting from ED as suggested by the guidelines; 3 Any observation in the care area of medium intensity with careful monitoring for the subpopulation of patients with finding of right ventricular dilation or myocardial enzyme elevation (considered to be at high risk of shock and short–term mortality). Results We enrolled 248 patients, with a mean age of 83 years with female prevalence (F = 62%). Of these, 81 (32.7%) have organ damage and 86 (34.7%) have massive pulmonary embolism. Patients with organ damage received treatment with a higher adherence to the guidelines (68%) than those who did not have organ damage (51%) in a statistically significant way (p < 0.01). Patients with massive pulmonary embolism received treatment with a higher adherence to the guidelines (69 %) than those with peripheral pulmonary embolism (50%) in a statistically significant way (p < 0.005). Conclusions The study suggests that patients with organ damage or massive pulmonary embolism are more likely to receive treatment in the emergency room with greater compliance with international guidelines.

P275 HOLDING AREA IN EMERGENCY DEPARTMENT : A STRATEGY TO IMPROVE ADHERENCE TO INTERNATIONAL GUIDELINES IN CASES OF PULMONARY EMBOLISM IN ELDERLY

Abstract Premises Pulmonary embolism is a disease still characterized by high mortality. Despite a great development of the guidelines it is not clear what adherence to them is in real life, especially in the emergency room. Purpose of the Study See if and how, in the real life of an Emergency Department, adherence to the Guidelines varies according to the area to which the patient is addressed. Methods Monocentric retrospective observational study, on a group of geriatric patients (<75 y) that include all the people accessed to our ED, where they received acute PE dignosis. Enrolment started on 2016 and finished on 2019. We collected data from medical history, physical examination, lab tests, imaging; we calculated characteristic scores from the diagostic/therapeutic algorhitm, both regarding PE risk (Wells, Geneva and Years), and the 30–day mortality risk presentazione (sPESI). We then analized guidelines adherence in three decision–making turning–points: 1 Correct applicarion of decisional scores examined, which classify the patient in low, intermediate or high risk of PE, calculated with Wells and simplified Geneva score; 2 Correct therapy administration since the ED as suggested by the guidelines; 3 The eventual observation in the medium–intensity care area with close monitoring for the subpopulation of patients with finding of right ventricular dilation or myocardial enzymes impairement (considered at high risk of short–term shock and mortality). Results we enrolled 249 patients, with a mean age of 83 years and female prevalence (F = 62%). Of these, 69% were referred by Triage to medium–high intensity of care, the remaining 31% was directed to low intensity of care. 42.5% of the total patients were referred to OBI. The two areas of intensity of care showed similar adherence to guidelines (approximately 50%) without there being a statistically significant difference between the two areas (p > 0.05) Adherence to guidelines was higher in the holding area – OBI (75 %) compared to that of those managed in theaters (50%) in a statistically significant way (p < 0.001). Conclusions The study suggests that holding areas located in Emergency Departments can considerably increase adherence to international guidelines.

P273 MANAGEMENT OF ACUTE PULMONARY EMBOLISM IN GERIATRIC PATIENTS IN THE EMERGENCY ROOM: DOES ADHERENCE TO INTERNATIONAL GUIDELINES REDUCE IN ATYPICAL SYMPTOMS?

Abstract Purpose of the Study Evaluate if and how, in the real life of an Emergency Department, adherence to the Guidelines varies according to the presence of atypical symptoms. We understood dyspnoea, chest pain, signs and symptoms of deep vein thrombosis and syncope as typical symptoms. As atypical symptoms all the others (low–grade fever, vertigo …) Methods Single–center retrospective observational study on all geriatric patients (>75 y) who entered our ED, where they received a diagnosis of acute PE. Enrollment began in 2016 and ended in 2019. We collected data from medical history, physical examination, laboratory tests, imaging; we calculated the characteristic scores from the diagnostic/therapeutic algorithm, both for the risk of PE (Wells, Geneva and YEARS), and for the presentation of the risk of mortality at 30 days (sPESI). We then analyzed adherence to the guidelines in three decision turning points: 1 Correct application of the decision scores examined, which classify the patient at low, intermediate or high risk of PE, calculated with Wells and simplified Geneva score; 2 Correct administration of therapy starting from ED as suggested by the guidelines; 3 Any observation in the care area of medium intensity with careful monitoring for the subpopulation of patients with evidence of right ventricular dilation or myocardial enzyme elevation (considered to be at high risk of shock and short–term mortality). Results We enrolled 248 patients, with a mean age of 83 years with female prevalence (F = 63%). Of these, only 17 with atypical symptoms and 231 with typical symptoms. The vital signs were comparable in the two groups with no statistically significant difference (p > 0.05). Long–term outcomes such as mortality, need for hospitalization, hospitalization in intensive care and length of stay in hospital are also comparable results with no statistically significant difference (p > 0.05). However, adherence to international guidelines was statistically significantly lower in patients with atypical symptoms (33%) than in patients with typical symptoms (59%) (p < 0.05). Conclusions The study suggests that patients with atypical symptoms are more likely to have reduced adherence to international guidelines, most likely due to diagnostic delay.

The diagnostic value of D-dimer with simplified Geneva score (SGS) pre-test in the diagnosis of pulmonary embolism (PE)

BackgroundPulmonary embolism (PE) is the third most common cardiovascular syndrome with an average annual incidence rate of 77 per 100,000 population in the worldwide. The diagnose algorithms for suspected PE are generally include clinical scoring assessment and plasma D-dimer evaluation, patients with high risk of PE require computed tomographic pulmonary angiogram (CTPA) detection for confirmation.MethodsIn this retrospective analysis, 1035 patients with suspected PE were recruited. All the patients were clinically received simplified Geneva score (SGS) pre-test, determination of plasma D-dimer level, and CTPA detection. All enrolled patients were grouped according to the CTPA results: PE patients and non-PE patients. Then, receiver operating characteristic (ROC) curve were constructed to determine the optimal D-dimer cutoff point value which is based on Yonden’s index (YI).Results294 (28.4%) patients were confirmed with PE and 741(71.6%) individuals were regarded as non-PE cases by CTPA detection. Using the SGS pre-test, 829 (80.1%) patients were classified PE-unlikely (SGS ≤ 2) and 206 (19.9%) patients were PE-likely (SGS ≥ 3). Patients with D-dimer levels above 1.96 mg/L had a significant risk to suffer from PE (area under curve (AUC), 0.707; 95% CI, 0.678–0.735; p < 0.05). Meanwhile, in patients with SGS ≥ 3, the D-dimer cutoff point value moved to 2.2 mg/L (AUC, 0.644; 95% CI, 0.574–0.709; p < 0.05).ConclusionD-dimer test in combination with SGS pre-test could improve the accuracy of PE diagnosis. Patients with D-dimer levels over 1.96 mg/L (4 times of the normal level) have a significant risk for PE. In patients with SGS ≥ 3, the D-dimer cutoff point concentration for PE risk moves to the levels of 2.2 mg/L.

Age-dependent diagnostic accuracy of clinical scoring systems and D-dimer levels in the diagnosis of pulmonary embolism with computed tomography pulmonary angiography (CTPA).

The aim of this study was to compare the age-dependent diagnostic performance of clinical scores and D-dimer testing to identify patients with suspected pulmonary embolism (PE). Consecutive patients with suspected PE referred from the emergency department for computed tomography pulmonary angiography (CTPA) were retrospectively evaluated. Diagnostic scores (classic Wells score (WS), modified WS, simplified WS, revised Geneva score (GS), simplified GS, and YEARS score) were calculated from medical records. Results of D-dimer testing were retrieved from the laboratory database. CTPA was the diagnostic reference standard. Four age groups were analyzed (< 50, 50-64, 65-74, and ≥ 75years). Statistical analysis used receiver operating characteristics as well as uni- and multivariate analyses with calculation of prediction models. The study was IRB approved. One thousand consecutive patients were included. Areas under the curve (AUC) and accuracies were superior in patients < 50years. For the classic WS, the AUC decreased by 11% with the optimal cutoff dropping 1.5 points in patients ≥ 75years; for D-dimer levels, the optimal cutoff was 900μg/L higher in both ≥ 65years groups with a max. decrease of the AUC of 9%. In terms of accuracy, the YEARS score performed best across all groups. Classic WS and D-dimer level showed a significant interaction with patient age in prediction models. D-dimer measurement and clinical scores perform best in patients < 50years. The YEARS score performs best across all age groups and is therefore recommended. • The probability of pulmonary embolism predicted by fibrin fibrinogen degradation products and clinical scores shows the highest accuracy in patients < 50years. • The probability of pulmonary embolism predicted by the YEARS score shows the highest accuracy in each age group. • Classic Wells score and fibrin fibrinogen degradation products show a significant interaction with patient age in a logistic regression model.

Assessing clinical probability of pulmonary embolism: prospective validation of the simplified Geneva score

Background Pretest probability assessment by a clinical prediction rule (CPR) is an important step in the management of patients with suspected pulmonary embolism (PE). A limitation to the use of CPRs is that their constitutive variables and corresponding number of points are difficult to memorize. A simplified version of the Geneva score (i.e. attributing one point to each variable) has been proposed but never been prospectively validated. Aims Prospective validation of the simplified Geneva score (SGS) and comparison with the previous version of the Geneva score (GS). Methods In the ADJUST-PE study, which had the primary aim of validating the age-adjusted D-dimer cut-off, the SGS was prospectively used to determine the pretest probability in a subsample of 1621 study patients. Results Overall, PE was confirmed in 294 (18.1%) patients. Using the SGS, 608 (37.5%), 980 (60.5%) and 33 (2%) were classified as having a low, intermediate and high clinical probability. Corresponding prevalences of PE were 9.7%, 22.4% and 45.5%; 490 (30.1%) patients with low or intermediate probability had a D-dimer level below 500μgL-1 and 653 (41.1%) had a negative D-dimer test according to the age-adjusted cut-off. Using the GS, the figures were 491(30.9%) and 650 (40.9%). None of the patients considered as not having PE based on a low or intermediate SGS and negative D-dimer had a recurrent thromboembolic event during the 3-month follow-up. Conclusions The use of SGS has similar efficiency and safety to the GS in excluding PE in association with the D-dimer test.

Prognostic value of the Geneva prediction rule in patients with pulmonary embolism

BackgroundAssessment of pre-test probability of pulmonary embolism (PE) and prognostic stratification are two widely recommended steps in the management of patients with suspected PE. Some items of the Geneva prediction rule may have a prognostic value.We analyzed whether the initial probability assessed by the Geneva rule was associated with the outcome of patients with PE. MethodsIn a post-hoc analysis of a multicenter trial including 1,693 patients with suspected PE, the all-cause death or readmission rates during the 3-month follow-up of patients with confirmed PE were analyzed. PE probability group was prospectively assessed by the revised Geneva score (RGS). Similar analyses were made with the a posteriori-calculated simplified Geneva score (SGS). ResultsPE was confirmed in 357 patients and 21 (5.9%) died during the 3-month follow-up. The mortality rate differed significantly with the initial RGS group, as with the SGS group. For the RGS, the mortality increased from 0% (95% Confidence Interval: [0–5.4%]) in the low-probability group to 14.3% (95% CI: [6.3-28.2%]) in the high-probability group, and for the SGS, from 0% (95% CI: [0–5.4%] to 17.9% (95% CI: [7.4-36%]). Readmission occurred in 58 out of the 352 patients with complete information on readmission (16.5%). No significant change of readmission rate was found among the RGS or SGS groups. ConclusionsReturning to the initial PE probability evaluation may help clinicians predict 3-month mortality in patients with confirmed PE.(ClinicalTrials.gov: NCT00117169)

Clinical probability of pulmonary embolism: Comparison of different scoring systems

Pulmonary embolism is one of the greatest diagnostic challenges in emergency medicine and clinical probability assessment is a fundamental step in its diagnosis. AimTo evaluate the role of estimating clinical probability of pulmonary embolism and to compare between different pre-test probability scoring systems as regards their sensitivity and specificity. Patients and methodsWe used seven scoring systems (original Geneva score, revised Geneva score, simplified Geneva score, Wells score, simplified Wells score, simplified Charlotte rule, Pisa model) to assess the clinical probability of PE in 41 patients with suspected pulmonary embolism for whom the final diagnosis was based on multislice CT pulmonary angiography (CTPA). ResultsTwenty-four patients (58.5%) had pulmonary embolism. The scores with the strongest correlation with the result of CTPA were the Pisa model (P⩽0.001) followed by the original Geneva score and the Wells score (P⩽0.01). Simplified Wells score had the highest sensitivity (0.92), Pisa model had the highest specificity (0.82) and the highest overall accuracy (0.76). ConclusionFor most patients, clinical probability assessment is an easy and effective way to decide which patient should undergo further investigations. Among the studied seven scores, the Pisa model has the best correlation with the CTPA results and it has a good sensitivity, specificity, positive and negative predictive values and the highest overall accuracy.

The Simplified Geneva Score and the Utilization of the D-Dimer and Computerized Tomography for Assessing Pulmonary Embolism

Background. Pulmonary embolism (PE) is clinically suspected in many patients who complain of shortness of breath or chest pain due to its nonspecific nature. The prevalence of PE, however, is low in this population. To assist physicians in diagnostic decision making, several clinical decision rules (CDR) have been developed. The appropriate use of these CDRs has been proven to decrease the need for expensive, time consuming, and invasive diagnostic imaging procedures. In this study, the appropriateness of D-dimer and CT usage was investigated to rule out pulmonary emboli based on the simplified Geneva score. Methods. A retrospective review was performed on 74 patients with a CT scan ordered through a pulmonary embolism (PE) protocol. Using clinical data, the patients were stratified into “unlikely” and “likely” groups for the presence of PE based on the simplification of the revised Geneva score. Scores of 0-2 were graded as “unlikely” and scores of 3 or greater were “likely.” Results. There were 45/74 (60.8%) patients in the “unlikely” group. Of these, 14/45 (31.1%) received a D-dimer; eight were normal and six elevated. Only one patient in the elevated group had evidence of a PE. Of the remaining 31(39.2%) patients in the “unlikely” group that did not receive a D-dimer, only one had a PE. The “likely” group consisted of 29 (39.2%) patients of whom six received a D-dimer. Three patients had a normal D-dimer and three had an elevated level. Neither of these two groups had a PE. Of the remaining 23 (60.8%) in the “likely” group who did not receive a D-dimer, six had a PE. Conclusions. Diagnosing pulmonary emboli using D-dimer levels and CT scans may be aided by clinical decision rules such as the simplified Geneva system. This process may lead to more effective use of medical resources.

Prognostic value of the Geneva prediction rule in patients in whom pulmonary embolism is ruled out

The prognosis of patients in whom pulmonary embolism (PE) is suspected but ruled out is poorly understood. We evaluated whether the initial assessment of clinical probability of PE could help to predict the prognosis for these patients. Retrospective analysis of data obtained during a prospective multicentre management study. Six general and teaching hospitals in Belgium, France and Switzerland. In 1334 patients in whom PE was ruled out, 3-month mortality data were available (hospital readmission status was unknown for three patients) and clinical probability was evaluated with the revised Geneva score (RGS). Three-month mortality and readmission rates. Three-month mortality and readmissions rates were 3% and 19%, respectively and differed significantly depending on the RGS-determined PE probability group (P<0.001). When compared with patients presenting with a low probability, the risk of death after 3 months was higher in cases of intermediate or high RGS-based probability {odds ratio: 8.7 [95% confidence interval (CI): 2.7-28.5] and 22.6 (95%CI: 2.1-241.2), respectively}. The readmission risk increased with PE probability group (P<0.001). The main causes of death were cancer, respiratory failure and cardiovascular failure. In total, 86% of patients with low RGS-based probability were alive and had not been readmitted to hospital, whereas other patients had a twofold increased risk of death or readmission during the 3-month follow-up. The simplified Geneva score, calculated a posteriori, gave similar results. Initial assessment of clinical probability may help to stratify prognosis of patients in whom PE has been ruled out. Patients with a low probability of PE have a good prognosis. Whether patients with higher probability might benefit from more vigilant care should be evaluated.