Isabelle Colombet

Prognostic value of right ventricular dysfunction in patients with haemodynamically stable pulmonary embolism: a systematic review

AIMS To determine the prognostic value of right ventricular (RV) dysfunction assessed by echocardiography or spiral computed tomography (CT), or by increased levels of cardiac biomarkers [troponin, brain natriuretic peptide (BNP) and pro-BNP] in patients with haemodynamically stable pulmonary embolism (PE). METHODS AND RESULTS We included all studies published between January 1985 and October 2007 estimating the relationship between echocardiography, CT or cardiac biomarkers and the risk of death in patients with haemodynamically stable PE. Twelve of 722 potentially relevant studies met inclusion criteria. The unadjusted risk ratio of RV dysfunction as assessed by echocardiography (five studies) or by CT (two studies) for predicting death was 2.4 [95% confidence interval (CI) 1.3-4.4]. The unadjusted risk ratio for predicting death was 9.5 (95% CI 3.2-28.6) for BNP (five studies), 5.7 (95% CI 2.2-15.1) for pro-BNP (two studies) and 8.3 (95% CI 3.6-19.3) for cardiac troponin (three studies). Threshold values differed substantially between studies for all markers. CONCLUSION RV dysfunction assessed by CT, echocardiography, or by cardiac biomarkers are all associated with an increased risk of mortality in patients with haemodynamically stable PE. These findings should be interpreted with caution because of the clinical and methodological diversity of studies.

Systematic review and meta-analysis of strategies for the diagnosis of suspected pulmonary embolism

Abstract Objectives To assess the likelihood ratios of diagnostic strategies for pulmonary embolism and to determine their clinical application according to pretest probability. Data sources Medline, Embase, and Pascal Biomed and manual search for articles published from January 1990 to September 2003. Study selection Studies that evaluated diagnostic tests for confirmation or exclusion of pulmonary embolism. Data extracted Positive likelihood ratios for strategies that confirmed a diagnosis of pulmonary embolism and negative likelihood ratios for diagnostic strategies that excluded a diagnosis of pulmonary embolism. Data synthesis 48 of 1012 articles were included. Positive likelihood ratios for diagnostic tests were: high probability ventilation perfusion lung scan 18.3 (95% confidence interval 10.3 to 32.5), spiral computed tomography 24.1 (12.4 to 46.7), and ultrasonography of leg veins 16.2 (5.6 to 46.7). In patients with a moderate or high pretest probability, these findings are associated with a greater than 85% post-test probability of pulmonary embolism. Negative likelihood ratios were: normal or near normal appearance on lung scan 0.05 (0.03 to 0.10), a negative result on spiral computed tomography along with a negative result on ultrasonography 0.04 (0.03 to 0.06), and a D-dimer concentration < 500 μg/l measured by quantitative enzyme linked immunosorbent assay 0.08 (0.04 to 0.18). In patients with a low or moderate pretest probability, these findings were associated with a post-test probability of pulmonary embolism below 5%. Spiral computed tomography alone, a low probability ventilation perfusion lung scan, magnetic resonance angiography, a quantitative latex D-dimer test, and haemagglutination D-dimers had higher negative likelihood ratios and can therefore only exclude pulmonary embolism in patients with a low pretest probability. Conclusions The accuracy of tests for suspected pulmonary embolism varies greatly, but it is possible to estimate the range of pretest probabilities over which each test or strategy can confirm or rule out pulmonary embolism.

Effect of Alerts for Drug Dosage Adjustment in Inpatients with Renal Insufficiency

OBJECTIVES Medication errors constitute a major problem in all hospitals. Between 20% and 46% of prescriptions requiring dosage adjustments based on renal function are inappropriate. This study aimed to determine whether implementing alerts at the time of ordering medication integrated into the computerized physician order entry decreases the proportion of inappropriate prescriptions based on the renal function of inpatients. DESIGN Six alternating 2-month control and intervention periods were conducted between August 2006 and August 2007 in two medical departments of a teaching hospital in France. A total of 603 patients and 38 physicians were included. During the intervention periods, alerts were triggered if a patient with renal impairment was prescribed one of the 24 targeted drugs that required adjustment according to estimated glomerular filtration rate (eGFR). MEASUREMENTS The main outcome measure was the proportion of inappropriate first prescriptions, according to recommendation. RESULTS A total of 1,122 alerts were triggered. The rate of inappropriate first prescriptions did not differ significantly between intervention and control periods (19.9% vs. 21.3%; p=0.63). The effect of intervention differed significantly between residents and senior physicians (p=0.03). Residents tended to make fewer errors in intervention versus control periods (Odds ratio 0.69; 95% confidence interval 0.41 to 1.15), whereas senior physicians tended to make more inappropriate prescriptions in intervention periods (odds ratio 1.88; 95% confidence interval 0.91 to 3.89). CONCLUSION Alert activation was not followed by a significant decrease in inappropriate prescriptions in our study. Thus, it is still necessary to evaluate the impact of these systems if newly implemented in other settings thanks to studies also designed to watch for possible unanticipated effects of decision supports and their underlying causes.

Agreement between Erythrocyte Sedimentation Rate and C-Reactive Protein in Hospital Practice

BACKGROUND Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) are frequently prescribed jointly. The usefulness of this practice is uncertain. METHODS All patients with ESR and CRP measured at the same time in an academic tertiary hospital during a 1-year period were included. Concomitant measures of serum creatinine, hematocrit, and anti-Xa activity were recorded to study noninflammatory cause of increased ESR. Level of agreement between ESR and CRP was assessed with kappa coefficient, and their accuracy was determined in a medical chart review of 99 randomly selected patients with disagreement between both markers. RESULTS Among 5777 patients, 35% and 58% had an elevated CRP and ESR, respectively. ESR and CRP were in agreement in 67% of patients (both elevated in 30%, both normal in 37%). A disagreement was observed in 33% (elevated ESR/normal CRP in 28%, normal ESR/elevated CRP in 5%). The kappa coefficient showed poor agreement (k=0.38) between both markers. Review of medical chart showed that 25 patients with elevated CRP and normal ESR had an active inflammatory disease (false-negative ESR). Conversely, 74 patients had elevated ESR and normal CRP-32% had resolving inflammatory disorders, 28% disclosed a variable interfering with the ESR measure (false-positive ESR), 32% had unexplained discrepancies, and 8% had an active inflammatory disease (false-negative CRP). CONCLUSION In hospital practice, joint measurement of ESR and CRP is unwarranted. Because of slow variation and frequent confounding, ESR is frequently misleading in unselected patients. When an inflammatory disorder is suspected, priority should be given to CRP.

An overview of the effect of computer-assisted management of anticoagulant therapy on the quality of anticoagulation

Risks and benefits of anticoagulant therapy depend directly of the quality of anticoagulation. We carried out a meta-analysis of published randomized trials to assess the overall effectiveness of computer-assisted prescription systems on the quality of anticoagulation. Randomized controlled trials were identified through electronic searches of the Medline database (1966-1997) and systematic analyses of the references of articles. Two investigators selected relevant papers and summarized data from the studies. The outcome variable was the proportion of days within the target range of anticoagulation. A pooled estimate of the common odds ratio of being in the target range and its confidence interval was obtained by the Mantel-Haenszel method. Nine trials having included 1336 patients were identified. Computer systems were based on a pharmacokinetic-pharmacodynamic model and a bayesian prediction method. Most of them concerned the oral anticoagulant warfarin. The global odds ratio of being in the target range was 1.29 [95% CI: 1.17-1.49], thus meaning that the use of a computer for anticoagulation optimization increased by 29% the proportion of visits where patients were appropriately treated. The proportion of clinical events was too low for allowing a summary analysis, but major hemorrhages tended to be less frequent among patients of the computer groups than among patients of the control groups (2.0 versus 3.9%). Evidence from randomized controlled trials supports the effectiveness of computer-aided anticoagulant prescription. Widespread use of these systems in ambulatory care could increase the benefit/risk ratio of anticoagulant treatment at a low cost.

Diagnosis of tetanus immunization status: multicenter assessment of a rapid biological test.

ABSTRACT Diagnosis of tetanus immunization status by medical interview of patients with wounds is poor. Many protected patients receive unnecessary vaccine or immunoglobulin, and unprotected patients may receive nothing. The aim of this study is to evaluate the feasibility and accuracy of the Tetanos Quick Stick (TQS) rapid finger prick stick test in the emergency department for determining immunization status. We designed a prospective multicenter study for blinded comparison of TQS with an enzyme-linked immunosorbent assay (ELISA). Adults referred for open wounds in 37 French hospital emergency departments had the TQS after receiving standard care (emergency-TQS). TQS was also performed in the hospital laboratory on total blood (blood/lab-TQS) and serum (serum/lab-TQS). ELISA was performed with the same blood sample at a central laboratory. We assessed concordance between emergency-TQS and blood/lab-TQS by the kappa test and the diagnostic accuracy (likelihood ratios) of medical interview, emergency-TQS, and lab-TQS. ELISA was positive in 94.6% of the 988 patients included. Concordance between blood/emergency-TQS and blood/lab-TQS results was moderate (κ = 0.6), with a high proportion of inconclusive blood/emergency-TQS tests (9.8%). Likelihood ratios for immunization were 3.0 (95% confidence interval [CI], 1.8 to 5.1), 36.6 (95% CI, 5.3 to 255.3), 89.1 (95% CI, 5.6 to 1,405.0), and 92.7 (95% CI, 5.9 to 1,462.0) for medical interview, blood/emergency-TQS, blood/lab-TQS, and serum/lab-TQS, respectively. The sensitivity of the blood/emergency-TQS was 76.7%, and the specificity was 98% by reference to the ELISA. TQS use in the emergency room could make tetanus prevention more accurate if its technical feasibility were improved, and our assessment will be supplemented by a cost effectiveness study.

Effect of integrated palliative care on the quality of end-of-life care: retrospective analysis of 521 cancer patients

Objective To examine the impact of oncologist awareness of palliative care (PC), the intervention of the PC team (PCT) and multidisciplinary decision-making on three quality indicators of end-of-life (EOL) care. Setting Cochin Academic Hospital, Paris, 2007–2008. Design and participants A 521 decedent case series study nested in a cohort of 735 metastatic cancer patients previously treated with chemotherapy. Indicators were location of death, number of emergency room (ER) visits in last month of life and chemotherapy administration in last 14 days of life. Multivariable logistic regression models were used to estimate associations between indicators and oncologists awareness of PC, PCT intervention and case discussions at weekly onco-palliative meetings (OPMs). Results 58 (11%) patients died at home, 45 (9%) in an intensive care unit or ER, and 253 (49%) in an acute care hospital; 185 (36%) patients visited the ER in last month of life and 75 (14%) received chemotherapy in last 14 days of life. Only the OPM (n=179, 34%) independently decreases the odds of receiving chemotherapy in last 14 days of life (OR 0.5, 95% CI 0.2 to 0.9) and of dying in an acute care setting (0.3, 0.1 to 0.5). PCT intervention (n=300, 58%) did not independently improve any indicators. Among patients seen by the PCT, early PCT intervention had no impact on indicators, whereas the OPM reduced the odds of persistent chemotherapy in the last 14 days of life. Conclusion Multidisciplinary decision-making with oncologists and the PCT is the most critical parameter for improving EOL care.

Development of a set of process and structure indicators for palliative care: the Europall project

BackgroundBy measuring the quality of the organisation of palliative care with process and structure quality indicators (QIs), patients, caregivers and policy makers are able to monitor to what extent recommendations are met, like those of the council of the WHO on palliative care and guidelines. This will support the implementation of public programmes, and will enable comparisons between organisations or countries.MethodsAs no European set of indicators for the organisation of palliative care existed, such a set of QIs was developed. An update of a previous systematic review was made and extended with more databases and grey literature. In two project meetings with practitioners and experts in palliative care the development process of a QI set was finalised and the QIs were categorized in a framework, covering the recommendations of the Council of Europe.ResultsThe searches resulted in 151 structure and process indicators, which were discussed in steering group meetings. Of those QIs, 110 were eligible for the final framework.ConclusionsWe developed the first set of QIs for the organisation of palliative care. This article is the first step in a multi step project to identify, validate and pilot QIs.

Electronic implementation of guidelines in the EsPeR system: A knowledge specification method

Despite initiatives to standardize methods for the development of clinical guidelines, several barriers hinder their integration in daily clinical practice: failure to fulfil quality criteria, poor effectiveness of their dissemination. Computerization of guidelines can favor their dissemination. The initial step of computerization is the knowledge specification from the text of the guideline. We describe the method of knowledge specification, which is used in EsPeR (Personalized Estimate of Risks), a web-based decision support system in preventive medicine, which allows, for a given person, to estimate risks and access recommendations, based on clinical profile. This method is based on a structured and systematic analysis of text allowing detailed specification of a decision tree. We use decision tables to validate the decision algorithm and decision trees to specify this algorithm, along with elementary messages of recommendation. Editing tools are used to facilitate the process of validation and the workflow between expert physicians and computer scientists. Applied to eleven different guidelines, the method allows a quick and valid computerization and integration in the EsPeR system. The method used for computerization could help to define a framework usable at the initial step of guideline development in order to produce guidelines ready for electronic implementation.

A computer decision aid for medical prevention: a pilot qualitative study of the Personalized Estimate of Risks (EsPeR) system

BackgroundMany preventable diseases such as ischemic heart diseases and breast cancer prevail at a large scale in the general population. Computerized decision support systems are one of the solutions for improving the quality of prevention strategies.MethodsThe system called EsPeR (Personalised Estimate of Risks) combines calculation of several risks with computerisation of guidelines (cardiovascular prevention, screening for breast cancer, colorectal cancer, uterine cervix cancer, and prostate cancer, diagnosis of depression and suicide risk). We present a qualitative evaluation of its ergonomics, as well as its understanding and acceptance by a group of general practitioners. We organised four focus groups each including 6–11 general practitioners. Physicians worked on several structured clinical scenari os with the help of EsPeR, and three senior investigators leaded structured discussion sessions.ResultsThe initial sessions identified several ergonomic flaws of the system that were easily corrected. Both clinical scenarios and discussion sessions identified several problems related to the insufficient comprehension (expression of risks, definition of familial history of disease), and difficulty for the physicians to accept some of the recommendations.ConclusionEducational, socio-professional and organisational components (i.e. time constraints for training and use of the EsPeR system during consultation) as well as acceptance of evidence-based decision-making should be taken into account before launching computerised decision support systems, or their application in randomised trials.