The Thoracic Society of Australia and New Zealand
The Thoracic Society of Australia and New Zealand (TSANZ) is the only health peak body representing a range of professions (medical specialists, scientists, researchers, academics, nurses, physiotherapists, students and others) across various disciplines within the respiratory/sleep medicine field in Australia and New Zealand. The TSANZ is a Health Promotion Charity. TSANZ is committed to serving the professional needs of its members by improving knowledge and understanding of lung disease, with the ultimate goals being to prevent respiratory illness through research and health promotion and to improve health care for people with respiratory illness.
6.
Do not perform a D-Dimer in patients at high risk of pulmonary embolism
The sequence for diagnostic testing in patients with suspected pulmonary embolism (PE) depends on the clinical circumstances. The certainty of a negative diagnosis for PE via an algorithm including a negative D-dimer result is enhanced when the algorithm follows a multibranch diagnostic pathway. While combining a negative D-dimer result with a low or moderate clinical probability for PE rules out these diagnoses, the use of D-dimer is not helpful in patients with a high probability clinical assessment since a negative D-dimer does not exclude PE in more than 15 percent of such patients.
According to Wells’ criteria for deep vein thrombosis, a score of less than two indicates low risk, and above two indicates intermediate/high risk. The high score is ≥4.5 in the two-tier model and >6 in the three-tier model (2-6 indicates moderate risk in this model).
Supporting evidence
- An evaluation of D-dimer in the diagnosis of pulmonary embolism: a randomized trial. Kearon C, Ginsberg JS, Douketis J, Turpie AG, Bates SM, Lee AY, Crowther MA, Weitz JI, Brill-Edwards P, Wells P, Anderson DR, Kovacs MJ, Linkins LA, Julian JA, Bonilla LR, Gent M, Canadian
- D-dimer for the exclusion of acute venous thrombosis and pulmonary embolism: a systematic review. Stein PD, Hull RD, Patel KC, Olson RE, Ghali WA, Brant R, Biel RK, Bharadia V, Kalra NK, Ann Intern Med. 2004;140(8):589
- D-dimer test for excluding the diagnosis of pulmonary embolism. Crawford F, Andras A, Welch K, Sheares K, Keeling D, Chappell FM. Cochrane Database of Systematic Reviews 2016, Issue 8. Art. No.: CD010864
- Diagnosis of pulmonary embolism by multidetector CT alone or combined with venous ultrasonography of the leg: a randomised non-inferiority trial. Righini M, Le Gal G, Aujesky D, Roy PM, Sanchez O, Verschuren F, Rutschmann O, Nonent M, Cornuz J, Thys F, Le Manach CP, Revel MP, Poletti PA, Meyer G, Mottier D, Perneger T, Bounameaux H, Perrier A, Lancet. 2008 Apr;371(9621):1343-52
- Pulmonary Embolism Diagnosis Study (CANPEDS) Group Ann Intern Med. 2006;144(11):812
- Diagnostic pathways in acute pulmonary embolism: recommendations of the PIOPED II investigators. Stein PD, Woodard PK, Weg JG, Wakefield TW, Tapson VF, Sostman HD, Sos TA, Quinn DA, Leeper KV Jr, Hull RD, Hales CA, Gottschalk A, Goodman LR, Fowler SE, Buckley JD, PIOPED II investigators, Am J Med. 2006;119(12):1048
- Wells PS, Anderson DR, Rodger M, Forgie M, Kearon C, Dreyer J, Kovacs G, Mitchell M,
- Lewandowski B, Kovacs MJ. Evaluation of D-dimer in the diagnosis of suspected deep-vein thrombosis. N Engl J Med. 2003 Sep 25;349(13):1227-35. doi: 10.1056/NEJMoa023153. PMID: 14507948.
How this list was made
In 2018 The Royal Australasian College of Physicians worked with a Lead Fellow nominated by The Thoracic Society of Australia and New Zealand (TSANZ) to review evidence for 12 paediatric thoracic recommendations on low-value care in paediatric thoracic medicine. These recommendations were the subject of email discussions and deliberation by members of the Paediatric Special Interest Group (SIG) of the TSANZ. They were further discussed at a workshop held at a meeting of the Asia Pacific Society of Respirology in 2017, which included TSANZ members. Based on the feedback provided at this workshop and through email discussions with members of the SIG, four were removed and two of the original 12 were considered for inclusion in the final recommendations with overwhelming support. Members of the Paediatric SIG were then invited to choose three out of the remaining six through an email based poll. This served as the basis for final recommendations, which were further refined and developed through successive drafts based on the input of the Lead Fellow, the results of consultation with other specialty groups and the views of the TSANZ Board.
In 2020 TSANZ worked with RACP’s Policy & Advocacy team as part of the Evolve program to develop a long list of low-value practices and interventions that pertain to the specialty. Through extensive research and redrafting under the guidance of the TSANZ Central Office and members of the TSANZ Board, the list was condensed to the top-5 recommendations for reducing low-value practices in adult thoracic medicine. After several rounds of internal consultations and revisions, the list of recommendations was subject to an extensive review process that involved key College societies with an interest in or professional engagement with thoracic medicine.
Per usual processes, the recommendations were then consulted with other medical colleges through Choosing Wisely Australia. Feedback received in the consultations led to further work and refinements by Policy & Advocacy and TSANZ, which approved these top-5 recommendations.
- 1 Do not prescribe combination therapy (inhaled corticosteroids with long-acting beta2 agonist) as initial therapy in mild to moderate asthma before a trial of inhaled corticosteroids alone.
- 2 Do not prescribe antibiotics for exacerbation of asthma.
- 3 Do not use oral beta2 agonists as bronchodilators in asthma, wheeze or bronchiolitis.
- 4 For children with bronchiolitis without other co-morbidities, do not delay discharge from an inpatient admission based on oxygen saturations alone if saturations are ≥90%.
- 5 Do not delay immunisation/s based on presence of mild respiratory symptoms in the absence of fever.
- 6 Do not perform a D-Dimer in patients at high risk of pulmonary embolism
- 7 Do not use long term systemic corticosteroids for management of chronic obstructive pulmonary disease (COPD)
- 8 Do not initiate maintenance inhalers in minimally symptomatic COPD patients with a low risk of exacerbation
- 9 Do not routinely follow-up solid pulmonary nodules smaller than 6 mm detected in low- risk patients
- 10 Do not perform a serum ACE for the diagnosis or monitoring of sarcoidosis