PROPER RCT - PERC Stands the Test

Written by Alex Chen, MD

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In low-risk patients with suspected PE, PERC was not inferior to a conventional strategy. The PERC group underwent 10% fewer CTPA studies, had a decreased ED length of stay of 36 minutes, and a decrease in hospital admission of 3.3%.

Why does this matter?
Pulmonary embolism is one of those diseases that is uncommon but can lead to significant morbidity and mortality. This leads to a great deal of hand-wringing and aggressive testing with results that we don’t always know what to do with. This RCT adds evidence that PERC has more generalizability.

There are perks to using PERC
This was a crossover cluster RCT conducted in 14 EDs throughout France. They enrolled 1914 patients with new-onset of chest pain or worsening shortness of breath with a low clinical probability of PE by gestalt (<15%). They randomized which protocol (PERC vs usual care) the ED started, with a 2 month wash-out period in between. Individual patients were not randomized. The PERC group had a PE rate of 1.5% vs 2.7% in the control group. The primary outcome was symptomatic thromboembolic event at 3 months. One patient (0.1%) was missed in the PERC group compared to none in the control group. There was no significant difference in all-cause mortality at 3 months (0.3% vs 0.2%), however the study was not powered to detect this. In terms of resource utilization for the PERC group, there was a 10% reduction in CTPA usage, 36 minute reduction in the median ED LOS, and a 3.3% reduction in hospital admission rates.

Source
Effect of the Pulmonary Embolism Rule-Out Criteria on Subsequent Thromboembolic Events Among Low-Risk Emergency Department Patients: The PROPER Randomized Clinical Trial.  JAMA. 2018 Feb 13;319(6):559-566. doi: 10.1001/jama.2017.21904.

Reviewed by Thomas Davis and Clay Smith.

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