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Caution on Interpreting the Time Trends in Pulmonary Embolism as “Overdiagnosis”

Caution on Interpreting the Time Trends in Pulmonary Embolism as “Overdiagnosis” Wiener et al1(p831) conclude that the “introduction of CTPA [computed tomographic pulmonary angiography] was associated with changes consistent with overdiagnosis” of acute pulmonary embolism (PE) and suggest that such overdiagnosis is leading to increasing anticoagulant-related bleeding complications from overtreatment with no reduction in mortality. The authors' title suggests that they report “evidence of overdiagnosis.” However, it is important to point out that no direct evidence of overdiagnosis is presented. Specifically, only the incidence of PE hospital discharge diagnosis codes from aggregate administrative-level data are reported; PE incidence by review of individual-level medical records using accepted criteria for objectively diagnosed PE was not measured. Limitations with the use of administrative data may have lead to overestimation of disease trends, especially with the trend of “upcoding” over time in an effort to maximize reimbursement. Thus, trends in PE incidence over time cannot be accurately estimated from this study. Similarly, since PE diagnosed by CTPA also was not measured, trends in the incidence of PE diagnosed by CTPA cannot be estimated. Because most acute PE deaths are sudden deaths,2 these deaths would be unaffected by introduction of multidetector row CTPA, and it is not surprising that PE mortality did not decrease significantly over the study time frame. Finally, the authors report the incidence of discharge diagnosis codes for gastrointestinal and intracranial hemorrhage and for secondary thrombocytopenia, but no data are presented showing that such hemorrhage or thrombocytopenia was directly related to anticoagulation. The authors' list of “bleeding” codes was initially derived for patients known to be anticoagulated,3 but none of the code definitions specifically include hemorrhage related to anticoagulation. Moreover, the temporal sequence of events cannot be determined from discharge diagnosis codes. For example, a person with discharge diagnosis codes for PE and intracranial hemorrhage could have been admitted with a primary intracranial hemorrhage and developed a PE as a complication of the hospitalization. No direct evidence that the observed increase in incidence of bleeding discharge diagnosis codes over time was due to anticoagulation is presented. We believe it is inappropriate to imply that overuse of CTPA is leading to “overdiagnosis and overtreatment of PE” based solely on indirect evidence. Furthermore, we caution physicians not to increase their threshold for CTPA for patients with a moderate or high pretest probability of PE based on this study. Back to top Article Information Correspondence: Dr Ashrani, Divisions of Hematology, Mayo Clinic, 200 First St SW, Rochester, MN 55905 (ashrani.aneel@mayo.edu). Financial Disclosure: None reported. References 1. Wiener RS, Schwartz LM, Woloshin S. Time trends in pulmonary embolism in the United States: evidence of overdiagnosis. Arch Intern Med. 2011;171(9):831-83721555660PubMedGoogle ScholarCrossref 2. Heit JA, Silverstein MD, Mohr DN, Petterson TM, O’Fallon WM, Melton LJ III. Predictors of survival after deep vein thrombosis and pulmonary embolism: a population-based, cohort study. Arch Intern Med. 1999;159(5):445-45310074952PubMedGoogle ScholarCrossref 3. Witt DM, Delate T, Clark NP, et al; Warfarin Associated Research Projects and other EnDeavors (WARPED) Consortium. Outcomes and predictors of very stable INR control during chronic anticoagulation therapy. Blood. 2009;114(5):952-95619439733PubMedGoogle ScholarCrossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Internal Medicine American Medical Association

Caution on Interpreting the Time Trends in Pulmonary Embolism as “Overdiagnosis”

Archives of Internal Medicine , Volume 171 (21) – Nov 28, 2011

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Publisher
American Medical Association
Copyright
Copyright © 2011 American Medical Association. All Rights Reserved.
ISSN
0003-9926
eISSN
1538-3679
DOI
10.1001/archinternmed.2011.549
Publisher site
See Article on Publisher Site

Abstract

Wiener et al1(p831) conclude that the “introduction of CTPA [computed tomographic pulmonary angiography] was associated with changes consistent with overdiagnosis” of acute pulmonary embolism (PE) and suggest that such overdiagnosis is leading to increasing anticoagulant-related bleeding complications from overtreatment with no reduction in mortality. The authors' title suggests that they report “evidence of overdiagnosis.” However, it is important to point out that no direct evidence of overdiagnosis is presented. Specifically, only the incidence of PE hospital discharge diagnosis codes from aggregate administrative-level data are reported; PE incidence by review of individual-level medical records using accepted criteria for objectively diagnosed PE was not measured. Limitations with the use of administrative data may have lead to overestimation of disease trends, especially with the trend of “upcoding” over time in an effort to maximize reimbursement. Thus, trends in PE incidence over time cannot be accurately estimated from this study. Similarly, since PE diagnosed by CTPA also was not measured, trends in the incidence of PE diagnosed by CTPA cannot be estimated. Because most acute PE deaths are sudden deaths,2 these deaths would be unaffected by introduction of multidetector row CTPA, and it is not surprising that PE mortality did not decrease significantly over the study time frame. Finally, the authors report the incidence of discharge diagnosis codes for gastrointestinal and intracranial hemorrhage and for secondary thrombocytopenia, but no data are presented showing that such hemorrhage or thrombocytopenia was directly related to anticoagulation. The authors' list of “bleeding” codes was initially derived for patients known to be anticoagulated,3 but none of the code definitions specifically include hemorrhage related to anticoagulation. Moreover, the temporal sequence of events cannot be determined from discharge diagnosis codes. For example, a person with discharge diagnosis codes for PE and intracranial hemorrhage could have been admitted with a primary intracranial hemorrhage and developed a PE as a complication of the hospitalization. No direct evidence that the observed increase in incidence of bleeding discharge diagnosis codes over time was due to anticoagulation is presented. We believe it is inappropriate to imply that overuse of CTPA is leading to “overdiagnosis and overtreatment of PE” based solely on indirect evidence. Furthermore, we caution physicians not to increase their threshold for CTPA for patients with a moderate or high pretest probability of PE based on this study. Back to top Article Information Correspondence: Dr Ashrani, Divisions of Hematology, Mayo Clinic, 200 First St SW, Rochester, MN 55905 (ashrani.aneel@mayo.edu). Financial Disclosure: None reported. References 1. Wiener RS, Schwartz LM, Woloshin S. Time trends in pulmonary embolism in the United States: evidence of overdiagnosis. Arch Intern Med. 2011;171(9):831-83721555660PubMedGoogle ScholarCrossref 2. Heit JA, Silverstein MD, Mohr DN, Petterson TM, O’Fallon WM, Melton LJ III. Predictors of survival after deep vein thrombosis and pulmonary embolism: a population-based, cohort study. Arch Intern Med. 1999;159(5):445-45310074952PubMedGoogle ScholarCrossref 3. Witt DM, Delate T, Clark NP, et al; Warfarin Associated Research Projects and other EnDeavors (WARPED) Consortium. Outcomes and predictors of very stable INR control during chronic anticoagulation therapy. Blood. 2009;114(5):952-95619439733PubMedGoogle ScholarCrossref

Journal

Archives of Internal MedicineAmerican Medical Association

Published: Nov 28, 2011

Keywords: pulmonary embolism,overdiagnosis

References

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