Active implementation of a consensus strategy improves diagnosis and management in suspected pulmonary embolism

Our consensus-based strategy in the diagnostic management of patients with pulmonary embolism involves a perfusion lung scan, a ventilation lung scan, compression ultrasonography and pulmonary angiography, in sequence. We compared the diagnostic approach in patients with clinically suspected pulmonary embolism before the active implementation of this strategy (retrospective analysis of 618 patients, April 1992-March 1995) and after (prospective study of 250 patients, April 1995-March 1996), with another assessment 1 year later. The measured outcomes were: (i) final diagnosis of pulmonary embolism either directly by pulmonary angiography, indirectly by compression ultrasonography of the leg veins, or with a high probability from a ventilation/perfusion lung scan; (ii) prescription of anticoagulant therapy. Before strategy implementation, pulmonary embolism was adequately confirmed or excluded in 11% of patients with an abnormal perfusion lung scan; in 55% the diagnosis remained uncertain, but the patient received anticoagulants. After implementation, these figures were 58.5% and 13%, respectively. A modest further improvement was observed 1 year later. Active implementation of a consensus-based strategy in the diagnosis of pulmonary embolism increases definite diagnoses, and reduces the numbers treated with anticoagulants. It induces a rapid change in the diagnostic behaviour of physicians.