Kamphuisen P W, Jacobs E M G, Mol J J, Rijnders A J M, Ullmann E F
Afd. Interne Geneeskunde, Rijnstate Ziekenhuis, Arnhem.
Ned Tijdschr Geneeskd. 2002 Nov 2;146(44):2083-7.
To evaluate the active implementation of the Dutch Institute for Healthcare Improvement's guideline for the diagnostic work-up for pulmonary embolism in a general training hospital, and to analyse reasons for not following the guideline strategy.
Partly retrospective and partly prospective.
The diagnostic strategy was analysed for all consecutive patients with clinically suspected pulmonary embolism who underwent a perfusion lung scintigraphy. The extent to which the guideline was followed was investigated in the year before (July 1999-June 2000; n = 384) and the year after (July 2000-June 2001; n = 380) its active implementation. The possible reasons for not completing the strategy in the prospective cohort of the study were also analysed.
Following a non-high-probability perfusion-ventilation scan, the guideline was completed in 23/117 (20%) patients prior to the implementation and in 50/109 (46%) patients after the implementation of the guideline. In 27% and 60%, respectively, an additional duplex ultrasound of the legs was made to check for deep vein thrombosis, and in 65% and 70% respectively, pulmonary angiography was performed after a normal ultrasound result. The main reasons for not following the diagnostic work-up included low clinical probability (41%, without a proper alternative diagnosis), an alternative diagnosis (36%; pneumonia, heart failure, malignancy) and a reluctance to perform angiography. The mean age of the patients for whom the guideline was completed was lower (51 years) compared to patients for whom the guideline was not followed (65 years; p < 0.001). The risk of not completing the diagnostic workup in accordance with the guideline was six-fold higher for patients > or = 80 years compared with patients < 40 years of age, whereas an alternative diagnosis was not more prevalent in patients > or = 65 years.
Although active implementation of the guideline-based diagnostic work-up for pulmonary embolism increased the number of adequate diagnoses, the diagnostic work-up was not completed in half of the patients with inconclusive lung scans. The main reasons for this were the advanced age of the patient, alternative diagnoses, and a reluctance to perform pulmonary angiography.
评估一家普通培训医院对荷兰医疗保健改进研究所的肺栓塞诊断检查指南的积极实施情况，并分析未遵循指南策略的原因。
部分回顾性和部分前瞻性。
对所有连续接受灌注肺闪烁扫描的临床疑似肺栓塞患者的诊断策略进行分析。在指南积极实施前一年（1999年7月至2000年6月；n = 384）和实施后一年（2000年7月至2001年6月；n = 380）调查遵循指南的程度。还分析了研究前瞻性队列中未完成该策略的可能原因。
在进行非高概率灌注通气扫描后，指南实施前117例患者中有23例（20%）完成了检查，指南实施后109例患者中有50例（46%）完成了检查。分别有27%和60%的患者进行了额外的腿部双功超声检查以检查深静脉血栓形成，超声检查结果正常后分别有65%和70%的患者进行了肺血管造影。未遵循诊断检查的主要原因包括临床概率低（41%，无合适的替代诊断）、替代诊断（36%；肺炎、心力衰竭、恶性肿瘤）以及不愿进行血管造影。完成指南检查的患者平均年龄（51岁）低于未遵循指南的患者（65岁；p < 0.001）。与年龄<40岁的患者相比，年龄≥80岁的患者未按照指南完成诊断检查的风险高六倍，而在年龄≥65岁的患者中替代诊断并不更普遍。
尽管积极实施基于指南的肺栓塞诊断检查增加了充分诊断的数量，但在肺部扫描结果不确定的患者中，仍有一半未完成诊断检查。主要原因是患者年龄较大、存在替代诊断以及不愿进行肺血管造影。
