Questionnaire

As the first step of our study, we prepared a web‑based survey using the Delphi methodology.⁸ First, 3 authors (JS, ŁW, GK) suggested 65 questions, encompassing the following aspects: characteristics of a respondent and the respondent’s workplace, availability of diagnostic and therapeutic modalities, real‑life use of diagnostic, risk stratification, and therapeutic strategies, and in‑hospital and post‑PE care. This set of questions was sent to each author of this document for evaluation from 1 (irrelevant) to 10 (especially relevant). Questions with an average score above 7 were arbitrarily accepted, and those with an average score of 3 or below were rejected. The remaining questions were reassessed by the authors, and either dismissed or modified according to the reviewer’s suggestions. After the second round of the Delphi process, 65 questions were accepted, including 3 additional ones proposed during the first round and accepted in the second.

In this article, we analyze responses to 17 questions relating to current practices in diagnosis and risk stratification of PE.

Data collection

We used a commercially available web‑based survey tool (www.webankieta.pl) to collect the data. We aimed to obtain responses from hospital‑based physicians. All hospital departments of Małopolska, Podkarpacie, and Świętokrzyskie regions were identified using the Polish National Health Fund registries (www.nfz.gov.pl). First, an invitation letter including a link to the survey was emailed to the heads of 647 departments, asking all employed physicians to respond to the questionnaire. Next, a copy of the invitation letter was sent by regular mail to each department. Physicians working in pediatric and psychiatric wards were excluded. The responses were collected between June 20, 2022 and April 30, 2023.

Our analysis is based on responses to 17 questions described in the Supplementary material, Table S1.

Statistical analysis

Categorical variables were described as counts and percentages. Percentages were calculated for a nonmissing sample. To assess differences in selected diagnostic and risk stratification strategies between the groups we used the χ² test. The Bonferroni correction was applied when several diagnostic and risk stratification parameters were compared between the subgroups. The significance level was set at a P value below 0.01. Statistical analyses were performed with Statistica PL software (StatSoft, Inc., 2017, STATISTICA, version 13.3, Kraków, Poland).

We hypothesized that cardiologists from larger cities, working in hospitals with emergency departments (EDs) have more guideline‑directed clinical practices. Accordingly, the analyses were performed within prespecified subgroups, based on the type of specialization of a responding physician (cardiologists vs noncardiologists), years of clinical experience (up to or over 5), size of the city (up to or above 100 000 inhabitants), presence of an ED in the hospital, and formally approved procedure for diagnosing and treating PE in place.

Characteristics of the respondents

All respondents declared to be hospital‑based physicians, primarily working in departments such as cardiology, internal medicine, and ED, with a majority being specialists (Table 1). More than half reported to have a formally approved procedure for diagnosing and treating patients with APE or a dedicated unit for this purpose in their hospitals.

Use of diagnostic tests and assessment of pulmonary embolism probability

Less than half of the physicians (88; 40%) admitted to routinely using the revised Geneva or Wells clinical prediction rules for assessing the clinical probability of PE, as recommended by the 2019 ESC guidelines (Table 2). A majority of the respondents use them either occasionally (79; 36%) or never (52; 24%), preferring a clinical judgment. In contrast, D‑dimer levels are routinely assessed when diagnosing PE by nearly all respondents (198; 97.5%), but the age‑adjustment of the cutoff values is performed by only two‑thirds of the physicians (131; 65%). Computed tomography pulmonary angiography (CTPA) was reported to be the most commonly used diagnostic modality (189; 93%), whereas the use of echocardiography for diagnosis or risk stratification was reported by 148 physicians (73%).

Subgroup analyses on the use of diagnostic tests and assessment of pulmonary embolism probability

Cardiologists use echocardiography and D‑dimer age‑adjustment more commonly in their routine practice than noncardiologists (Figure 1, Supplementary material, Table S2). The presence of an ED is associated with the most frequent application of CTPA and D‑dimers for the PE diagnosis.

Risk assessment in acute pulmonary embolism patients

As presented in Figure 2, the most frequently used markers of prognosis in acute PE, reported by over 90% of the respondents, are blood pressure, oxygen saturation, and severity of symptoms, followed by heart rate, presence of a saddle thrombus on CTPA, blood troponin levels, right ventricular function on echocardiography, presence of central clots, and levels of N‑terminal pro–B‑type natriuretic peptide (NT‑proBNP). An expression “massive PE” on CTPA is considered a prognostic marker by 167 respondents (78.8%). The least commonly used risk predictors are the Bova scale, right‑to‑left ventricular ratio (RV/LV) on CTPA, and Pulmonary Embolism Score Index (PESI) or simplified PESI (sPESI) score.

Subgroup analyses of risk assessment in acute pulmonary embolism patients

Cardiologists are more likely than noncardiologists to use cardiac troponin levels, RV function on echocardiography, RV/LV ratio on CTPA, PESI/sPESI scores and NT‑proBNP levels for risk assessment (Figure 3, Supplementary material, Table S3). In hospitals with an ED, the echocardiography‑assessed RV function is used more often for prognosis than in hospitals without an ED.

Contacting pulmonary embolism response team for consultation

As many as 203 physicians (80.5%) have never consulted their acute PE patients with a PERT, despite the fact that 221 (88%) reported that they would if the PERT was available (Figure 4). In general, the responding physicians would seek PERT’s advice on patients without shock but with severe symptoms despite initial anticoagulation, on patients with shock and contraindications to systemic fibrinolysis, and on patients without shock or signs of RV dysfunction but with a diagnosis of massive PE on CTPA. As many as 74 respondents (29.4%) declared that they would consult a PERT on any PE patient with shock.

Subgroup analyses on seeking pulmonary embolism response team advice

The cardiologists and physicians with over 5 years of clinical experience would more often consult patients with shock and coexisting contraindications to systemic thrombolysis than the noncardiologists or physicians with a shorter experience (Supplementary material, Table S4), whereas the noncardiologists would more often consult patients without shock or signs of RV disfunction but with massive PE on CTPA (11 [15%] vs 72 [38%]; P = 0.002). Interestingly, doctors who once contacted PERT, would seek its advice again for every PE patient.

Limitations

A few limitations of our study should be mentioned. The focus on Polish medical practices may limit the generalizability of the findings to other health care systems; however, some similarities to previously published data^2-6 have been identified, such as limited use of prediction rules and potential overuse of CT imaging. A lack of a direct correlation between diagnostic strategies and patient outcomes may be regarded as a limitation of the study, as it could provide more conclusive evidence. The aim of the study, though, was to understand the current practices in the diagnosis of PE to identify potential areas of improvement to be addressed in the future. The study utilized a web‑based survey, which might introduce selection bias, as it relied on voluntary participation, potentially skewing results toward more engaged or technologically adept respondents. Limited rate of responses may also be regarded as a study drawback. On the other hand, the number of gathered responses may reflect only those physicians who have actual experience or a dedicated interest in PE care. If this were the case, then the actual awareness and knowledge of PE management would be even more limited.

Despite limitations, we believe that the study provided a valuable examination of current clinical practices in the diagnosis and risk stratification of PE, giving insights into the adherence to clinical practice guidelines almost 5 years after their publication. The originality of the study is the inclusion of various medical specialties from different hospital across the southern Poland. Its novelty lies in the fact that it assessed the actual use of risk assessment strategies, as such data have been limited so far. Also, capturing the respondent views on the most recent development in the management of PE patients, the PERTs, is a unique advantage of this study.

Conclusions

Adherence to guideline‑recommended clinical prediction rules in the diagnosis of acute PE is limited among physicians in Poland, and the reliance on D‑dimer appears to be the most common strategy. Risk stratification is largely based on individual experience and clinical judgement rather than evidence‑based strategies. The use of diagnostic algorithms and risk assessment models is heterogenous across different medical centers and medical specialties, with cardiologists from larger hospitals most frequently employing guideline‑recommended methods. By incorporating their expertise early in the PE management process, but also by broadening the knowledge and improving the skills of noncardiologists, general improvement in diagnostic precision could be expected. There is a high demand for the assistance of PERTs in the management of PE patients. Increasing the availability of PERTs and their cooperation with regional medical centers should become a nationwide number one initiative to reduce disparities in access to modern therapies and to improve patient care.