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W2998112255 abstract "The optimal approach to diagnosing pulmonary embolism (PE) in pregnancy is uncertain. Two studies published in the last year (Righini and YEARS) have recommended using D-dimer as an initial screening tool. In the Righini protocol, this was followed by compression ultrasound (CUS), CT pulmonary angiography (CTPA) and ventilation-perfusion scan (V/Q) as needed. The aim of this study was to determine which strategy for diagnosis of PE is least costly in pregnant women presenting with clinically suspected PE and a low-intermediate probability revised Geneva score. We compared the diagnostic strategy employed in the Righini study (D-dimer → CUS → CTPA → V/Q) to three other strategies: (1) no D-dimer; CUS → CTPA → V/Q, (2) no CUS; D-dimer → CTPA → V/Q, and (3) no D-dimer or CUS; CTPA → V/Q). We assumed that all diagnostic strategies would be equally effective and performed a cost-minimization analysis. We determined probabilities based on data from the Righini study and utilized US and Canadian cost data (Table 1). We performed a probabilistic sensitivity analysis using Monte Carlo microsimulation of 1,000 trials. We also performed a one-way sensitivity analysis varying the probability of a positive D-dimer. Of the four strategies, the least costly option was to proceed directly to CTPA (skipping D-dimer and CUS). The cost of each strategy per patient in the base case was as follows: study protocol (D-dimer → CUS → CTPA → V/Q), $1,126; no D-dimer (CUS → CTPA → V/Q), $1,164; no CUS (D-dimer → CTPA → V/Q), $655; no D-dimer or CUS (CTPA → V/Q), $617. Monte Carlo microsimulation showed starting with CTPA was the least costly option in 99.7% of trials. Finally, one-way sensitivity analysis showed that when the probability of a positive D-dimer is < 81%, the no CUS protocol (D-Dimer → CTPA → V/Q) becomes the least costly strategy (Figure 1). Our findings suggest that the least costly and most clinically efficient diagnostic algorithm would be to proceed directly to CTPA for women presenting with a clinically suspected PE and low-intermediate probability revised Geneva score.View Large Image Figure ViewerDownload Hi-res image Download (PPT)" @default.
W2998112255 created "2020-01-10" @default.
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W2998112255 date "2020-01-01" @default.
W2998112255 modified "2023-09-25" @default.
W2998112255 title "1138: Diagnosing pulmonary embolism in pregnancy: a cost-minimization analysis" @default.
W2998112255 doi "https://doi.org/10.1016/j.ajog.2019.11.1150" @default.
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