How Accurate Is Gestalt Alone for PE?

August 3, 2023

Written by Amanda Mathews

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In this individual patient data meta-analysis, researchers found that a positive clinician gestalt was associated with a three times higher risk of pulmonary embolism (PE) compared to negative gestalt.

Not another PE article
Is your head swimming with all the different algorithms and tools you can use to workup PE? These authors wanted to determine if clinician gestalt is accurate in the diagnosis of PE and if gestalt was variable over several patient characteristics and practice environments.

Sixteen studies including 20,770 individual patients were included in the meta-analysis. Gestalt was defined as “PE is the most likely diagnosis” – as seen in the Wells score – although a study did not need to use Wells to be included. Subgroup analysis of age, gender, comorbidities, practice environment, and other Wells criteria (previous DVT, immobility, etc) was conducted. The prevalence of PE in the positive gestalt group was 29% vs 9% in the negative gestalt group. The study used risk ratio (RR) to report association with gestalt and final diagnosis for PE. The overall RR was 3.02 (95%CI 2.35-3.87). Every subgroup analysis showed a positive RR. As a diagnostic test, gestalt was 74% (95%CI 68%-79%) sensitive and 61% (95%CI 53%-68%) specific.

This study had a few limitations. Clinician gestalt was scored differently in the studies included, with some studies incorporating gestalt in a clinical decision making tool, while other studies scored gestalt for research purposes only. There were also studies where gestalt was scored after the D-dimer test was completed, which would significantly influence a clinician’s response. Additionally, this study did not fully address the concern that gestalt is most directly affected by experience of the provider, as there was no measure in place to analyze provider experience level.

How will this change my practice?
Well, I’m not ready to throw out my clinical decision tools in favor of gestalt alone, and this study does not advocate for that. Gestalt will continue to feed into my pre-test probability for PE and will influence my workup in that manner. For the data-minded among us, this study gives numeric credence to the alarm bells that ring in your head when you are starting to suspect a patient might have a PE.

Source
Accuracy of the Physicians’ Intuitive Risk Estimation in the Diagnostic Management of Pulmonary Embolism: An Individual Patient Data Meta-Analysis. J Thromb Haemost. 2023 May 30:S1538-7836(23)00438-5. doi: 10.1016/j.jtha.2023.05.023. Epub ahead of print.