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Clinical characteristics associated with diagnostic delay of pulmonary embolism in primary care: a retrospective observational study
  1. Janneke M T Hendriksen1,
  2. Marleen Koster-van Ree1,
  3. Marcus J Morgenstern1,
  4. Ruud Oudega1,
  5. Roger E G Schutgens2,
  6. Karel G M Moons1,
  7. Geert-Jan Geersing1
  1. 1Department of Epidemiology, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
  2. 2Department of Internal Medicine, University Medical Center Utrecht, Van Creveldkliniek, Utrecht, The Netherlands
  1. Correspondence to Dr Janneke MT Hendriksen; jhendri9{at}


Objectives To evaluate the extent of delay in the diagnosis of pulmonary embolism (PE) in primary care, and to identify determinants that are associated with such diagnostic delay.

Design Retrospective observational study.

Setting 6 primary care practices across the Netherlands.

Participants Data from patients with an objectively confirmed diagnosis of PE (International Classification of Primary Care (ICPC) code K93) up to June 2015 were extracted from the electronic medical records. For all these PE events, we reviewed all consultations with their general practitioner (GP) and scored any signs and symptoms that could be attributed to PE in the 3 months prior to the event. Also, we documented actual comorbidity and the diagnosis considered initially.

Primary and secondary outcome measures Delay was defined as a time gap of >7 days between the first potentially PE-related contact with the GP and the final PE diagnosis. Multivariable logistic regression analysis was performed to identify independent determinants for delay.

Results In total, 180 incident PE cases were identified, of whom 128 patients had 1 or more potential PE-related contact with their GP within the 3 months prior to the diagnosis. Based on our definition, in 33 of these patients (26%), diagnostic delay was observed. Older age (age >75 years; OR 5.1 (95% CI 1.8 to 14.1)) and the absence of chest symptoms (ie, chest pain or pain on inspiration; OR 5.4 (95% CI 1.9 to 15.2)) were independent determinants for diagnostic delay. A respiratory tract infection prior to the PE diagnosis was reported in 13% of cases without delay, and in 33% of patients with delay (p=0.008).

Conclusions Diagnostic delay of more than 7 days in the diagnosis of PE is common in primary care, especially in the elderly, and if chest symptoms, like pain on inspiration, are absent.

  • pulmonary embolism
  • diagnostic delay
  • venous thromboembolism

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  • Contributors JMTH, G-JG and KGMM were involved in conception and design of the work. JMTH, MK-vR, MJM and G-JG were involved in data collection. JMTH, MK-vR, MJM, G-JG and KGMM were involved in data analysis and interpretation. JMTH, MK-vR, MJM and G-JG were involved in drafting the article. REGS, RO and KGMM were involved in critical revision of the article. JMTH, MK-vR, MJM, RO, REGS, KGMM and G-JG were involved in final approval of the version to be published.

  • Funding G-JG is supported by a VENI grant (91616030) from the Netherlands Organisation for Scientific Research (NWO). NWO had no influence on the writing, concept, study design or inferences of this study.

  • Competing interests None declared.

  • Ethics approval IRB UMC Utrecht.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement The data set and statistical codes are available from the authors on request.