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

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.