Clinical characteristics associated with diagnostic delay of pulmonary embolism in primary care: a retrospective observational study

• Published in: BMJ open 2017-03, Vol.7 (3), p.e012789-e012789
• Main Authors: Hendriksen, Janneke M T, Koster-van Ree, Marleen, Morgenstern, Marcus J, Oudega, Ruud, Schutgens, Roger E G, Moons, Karel G M, Geersing, Geert-Jan
• Format: Article
• Language: English
• Subjects: Age; Aged; Anticoagulants; Asthma; Cardiovascular disease; Chronic obstructive pulmonary disease; Comorbidity; Delayed Diagnosis; Disease; Dyspnea; Embolisms; Female; Gender; General Practice - statistics & numerical data; General practice / Family practice; Health risk assessment; Heart rate; Hospitals; Humans; Male; Medical diagnosis; Middle Aged; Netherlands; Observational studies; Oxygen saturation; Pain; Patients; Primary care; Pulmonary arteries; Pulmonary Embolism - diagnosis; Pulmonary embolisms; Respiration; Respiratory Tract Infections - diagnosis; Retrospective Studies; Risk factors; Systematic review; Thromboembolism; Thrombosis; Variables; Venous Thromboembolism - diagnosis
• ISSN: 2044-6055; 2044-6055
• DOI: 10.1136/bmjopen-2016-012789

ObjectivesTo evaluate the extent of delay in the diagnosis of pulmonary embolism (PE) in primary care, and to identify determinants that are associated with such diagnostic delay.DesignRetrospective observational study.Setting6 primary care practices across the Netherlands.ParticipantsData from patients with an objectively confirmed diagnosis of PE (International Classification of Primary Care (ICPC) code K93) up to June 2015 were extracted from the electronic medical records. For all these PE events, we reviewed all consultations with their general practitioner (GP) and scored any signs and symptoms that could be attributed to PE in the 3 months prior to the event. Also, we documented actual comorbidity and the diagnosis considered initially.Primary and secondary outcome measuresDelay was defined as a time gap of >7 days between the first potentially PE-related contact with the GP and the final PE diagnosis. Multivariable logistic regression analysis was performed to identify independent determinants for delay.ResultsIn total, 180 incident PE cases were identified, of whom 128 patients had 1 or more potential PE-related contact with their GP within the 3 months prior to the diagnosis. Based on our definition, in 33 of these patients (26%), diagnostic delay was observed. Older age (age >75 years; OR 5.1 (95% CI 1.8 to 14.1)) and the absence of chest symptoms (ie, chest pain or pain on inspiration; OR 5.4 (95% CI 1.9 to 15.2)) were independent determinants for diagnostic delay. A respiratory tract infection prior to the PE diagnosis was reported in 13% of cases without delay, and in 33% of patients with delay (p=0.008).ConclusionsDiagnostic delay of more than 7 days in the diagnosis of PE is common in primary care, especially in the elderly, and if chest symptoms, like pain on inspiration, are absent.