Does implementation of a diagnostic pathway for acute aortic syndrome including D-dimer increase the usage of D-dimer and computed tomography?

Abstract

Introduction

The Canadian clinical practice guidelines propose a novel diagnostic pathway incorporating a clinical decision tool and D-dimer to aid in risk stratifying patients for acute aortic syndrome. The objective of this study was to assess if implementation of a diagnostic pathway incorporating D-dimer would increase the usage of D-dimer and computed tomography (CT) in a tertiary care emergency department.

Methods

Prospective single centre before and after study-recruiting patients over a 6-week period from a tertiary care emergency department. Intervention: multi model implementation of a diagnostic pathway for acute aortic syndrome incorporating D-dimer. Outcome: proportion of patients receiving D-dimer testing/CT in the 2 weeks before and after implementation.

Results

We included 982 patients (Female 55%, Age mean 51.9, N = 492 pre intervention and N = 490 post intervention). The proportion that received a D-dimer test increased from 6.9 to 10.4% (p < 0.051), while the number of CT aortas remained stable (0.6% vs. 0.6%; p = 0.60). Documentation of pretest probability assessment increased from 1 to 3%, (p < 0.009) following the intervention. In the post intervention cohort, the tool was applied correctly in all cases (N = 17).

Conclusion

This single centre study found that a diagnostic pathway for acute aortic syndrome including D-dimer could be implemented without a significant increase in test ordering during this first 2 weeks after implementation. This study adds to the argument for use of D-dimer to help risk stratify patients for the diagnosis of acute aortic syndrome. Future studies are needed to confirm the diagnostic accuracy of this pathway and the long-term impact on resource utilization.

Résumé

Introduction

Les guides de pratique clinique canadiens proposent une nouvelle voie de diagnostic intégrant un outil de décision clinique et du D-dimère pour aider à stratifier le risque chez les patients atteints du syndrome aortique aigu. L’objectif de cette étude était d’évaluer si la mise en place d’une voie diagnostique intégrant le dimère-D augmenterait l’utilisation du dimère-D et de la tomodensitométrie (TDM) dans un service d’urgence de soins tertiaires.

Méthodes

Centre unique prospectif avant et après l'étude - recrutement de patients sur une période de 6 semaines à partir d'un service d'urgence de soins tertiaires. Intervention : mise en œuvre multi-modèle d’une voie diagnostique pour le syndrome aortique aigu intégrant le D-dimère. Résultat : Proportion de patients ayant subi un test des D-dimères/TDM dans les deux semaines précédant et suivant la mise en œuvre.

Résultats

Nous avons inclus 982 patients (femmes 55 %, âge moyen 51,9, N = 492 avant l’intervention et N = 490 après l’intervention). La proportion de personnes ayant reçu un test D-dimère est passée de 6,9 % à 10,4 % (p < 0,051), tandis que le nombre d’aortes CT est demeuré stable (0,6 % contre 0,6 %; p = 0,60). La documentation de l'évaluation de la probabilité avant le test est passée de 1 % à 3 % (p<0,009) après l'intervention. Dans la cohorte post-intervention, l'outil a été appliqué correctement dans tous les cas (n = 17).

Conclusion

Cette étude menée auprès d’un seul centre a révélé qu’une voie diagnostique pour le syndrome aortique aigu, y compris le D-dimère, pourrait être mise en œuvre sans qu’il y ait une augmentation significative de l’ordre des tests au cours des deux premières semaines suivant la mise en œuvre. Cette étude renforce l'argument en faveur de l'utilisation du D-dimère pour aider à stratifier les risques des patients pour le diagnostic du syndrome aortique aigu. De futures études sont nécessaires pour confirmer la précision du diagnostic de cette voie et l'impact à long terme sur l'utilisation des ressources.

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Contributions

RO was responsible for study design, analysis and manuscript preparation. NF, OM, AR and OB were responsible for data extraction. CD was responsible for manuscript editing, formatting and co-writing. RO acts as guarantor for accuracy and integrity of the manuscript.

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Correspondence to Robert Ohle.

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The authors declare that they have no conflict of interest.

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Ohle, R., Fortino, N., McIsaac, S. et al. Does implementation of a diagnostic pathway for acute aortic syndrome including D-dimer increase the usage of D-dimer and computed tomography?. Can J Emerg Med (2021). https://doi.org/10.1007/s43678-021-00096-w

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Keywords

  • Acute aortic syndrome
  • D-dimer
  • Computed tomography