Strategies for Suspected Pulmonary Embolism in Emergency Departments - SPEED Study
试验速览
- 阶段
- 不适用
- 状态
- 已完成
- 发起方
- 入组人数
- 1,331
- 试验地点
- 40
- 主要终点
- rate of agreement between the diagnostic criteria applied in daily practice and those validated in the scientific literature
研究概览
简要总结
Aims: 1) To evaluate the effectiveness of two interventions aimed at improving the management of patients with suspected pulmonary embolism: Written guidelines and Computer-Assisted Decision Support (CADS). 2) To evaluate the impact of electronic reminders on the appropriateness of the treatment of patients with suspected PE
Design: Pragmatic, unblinded, cluster randomised controlled study.
Setting: 20 French Emergency Departments
Patients: Out patients suspected of having pulmonary embolism
Methods: Emergency physicians will prospectively complete a standardized electronic form on Personal Data Assistant (PDA), including patients' characteristics, the clinical probability if assessed, the diagnostic tests performed, the treatments initiated and the final diagnostic and therapeutic decisions. Patients will be interviewed at the end of a 3-month follow-up period using a standardized questionnaire.
The reference rate of appropriateness of the diagnostic management before intervention will be assessed in each centre. At the end of this preliminary period, the centres will be randomized in two fold two groups according to a factorial design with stratification on their reference level of appropriateness. Half of the centres will have written guidelines and half a Computer-Assisted Decision Support for the diagnosis of PE on the PDA. In each of these two main groups, half of the centres will have electronic reminders on their PDA concerning the treatment of PE.
Judgment criteria
Main : Rate of strategies considered as validated according to the results of the systematic review and meta-analysis.3
Secondary judgment criteria (diagnosis):
- Rate of strategies considered as validated or acceptable according to the opinion of international advisors.
- Rate of thromboembolic-events during a 3-month follow-up period in patients for whom pulmonary embolism will be ruled out
- Costs of the diagnostic management
Secondary judgment criteria (treatment):
- Delay between Emergency Department admission and the first dose of antithrombotic treatment in patients with high clinical probability of PE according to the Revised Geneva Score
- Rate of inappropriate treatment according to international recommendations for patients with confirmed PE.
Number of patients: By estimating that the rate of appropriateness would be 55% in the "written guidelines" group, 1331 patients are necessary to highlight an absolute superiority of 15% in the "CADS" group (rate of conformity of 70%).
The number of patients will be adjusted at the end of the preliminary period according to the level of appropriateness before interventions considering that it will improve less than 5% in the "written guidelines" group.
详细描述
Background: The management of patients with suspected pulmonary embolism (PE) represents an important medical and economic issue. In French Emergency Departments, more than 100 000 suspicions of PE are dealt with per year. In a previous work, we found that the routine diagnostic practice differs to a large extent from international guidelines and that excluding PE on the basis of inappropriate criteria exposes patients to a six-fold increased risk of venous thromboembolism during 3-months follow-up.1 Passive interventions to improve quality are generally ineffective but Computer-Assisted Decision Support and reminders appear as promising.2
Interventions:
At the end of the preliminary period, we will perform for all the investigators, an interactive oral presentation of the strategies considered as validated on the basis of a systematic review and meta-analysis.3 A strategy end up to exclude PE is considered as validated if the probability of PE is below 5% and a strategy end up to confirm PE is considered as validated if the probability of PE is upper than 85%. The strategies that do not achieve these criteria but considered as acceptable by international advisors will be presented too as well as the recommendations for the treatment of PE.4 In the group "written guidelines", emergency physicians will be provided with cards presenting the list of the validated and acceptable strategies as well as the Geneva diagnostic algorithm.5 The algorithm will be mention as a way to follow appropriate diagnostic criteria.
In the "CADS" group, the recommendations will be integrated into the electronic form allowing calculation of the pre-test probability according to revised Geneva Score 6, calculation of the post-test probabilities according to the likelihood ratios of the tests 3 and contextualized reminders as which test perform or when stop investigations.
In the groups "treatment help", reminders concerning the treatment (indications and contraindications, dosage) will be integrated into the electronic form on the PDA.
研究设计
- 研究类型
- Interventional
- 分配方式
- Randomized
- 干预模型
- Parallel
- 盲法
- None
入排标准
- 性别
- All
- 接受健康志愿者
- 否
入选标准
- •patient with suspected pulmonary embolism
- •prescription of a specific paraclinical diagnostic investigation or start of a specific treatment for pulmonary embolism
排除标准
- •confirmation or exclusion of pulmonary embolism before admission in emergency department
- •confirmation of deep venous thrombosis before admission in emergency department
- •suspicion of pulmonary embolism during hospitalization (in-patient)
- •suspicion of pulmonary embolism without investigation realization
- •patient already included in the study
- •patient refusing the utilization of his data for the study
结局指标
主要结局
rate of agreement between the diagnostic criteria applied in daily practice and those validated in the scientific literature
次要结局
- -(diagnostic intervention) Rate of strategies considered as validated or acceptable according to the opinion of international advisors.
- - (diagnostic intervention) Rate of thromboembolic-events during a 3-month follow-up period in patients for whom pulmonary embolism will be ruled out
- - (diagnostic intervention) Costs of the diagnostic management
- - (therapeutic reminders) Delay between Emergency Department admission and the first dose of antithrombotic treatment in patients with high clinical probability of PE according to the Revised Geneva Score
- - (therapeutic reminders)Rate of inappropriate treatment according to international recommendations for patients with confirmed PE.