Are you guys using the age adjusted D-dimer?

[KGflyboy]

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Are you guys using agree adjusted D-dimer? And if so, do your lab reference values take age into consideration? Or do you just adjust the value to account for age on your own?

I would like to use the age adjusted dimer, but I am told our lab is not on board with this.

 

[RustedFox]

*Age adjusted.

I use it, and have an autotext specifically stating that this has been accepted as a "best practice" by (whoever), with the citation following.

 

[TooMuchResearch]

Your lab doesn't make your clinical decisions.

Are you guys using agree adjusted D-dimer? And if so, do your lab reference values take age into consideration? Or do you just adjust the value to account for age on your own?

I would like to use the age adjusted dimer, but I am told our lab is not on board with this.

 

[KGflyboy]

Your lab doesn't make your clinical decisions.

That's how I feel. But apparently nobody else I work with agrees. They throw out words like "local standard of care" that makes me feel like a rebel for even bringing up age adjusted cutoffs. In other words, the docs acknowledge the utility but just don't want to practice this way unless everybody else does it here.

 

[RustedFox]

Straight copy/pasted from my autotext treasure chest:

A d-dimer was ordered, which is only very marginally positive at a value of [ ]. When adjusted for the patient's age (Douma et al, JAMA - 2014), this value would be within the normal limits. This practice has been accepted by the American College of Physicians as a "clinical best policy practice" (Ann Inn Med. 2015 Nov 3 - available at ncbi.nlm.nih.cov/pubmed/26414967)

 

[carbonizedeyesockets]

Yes. And no, the lab does not adjust the upper limit according to age. I just state that the value is below the age adjusted limit of [whatever].

 

[RPedigo]

I definitely use an age-adjusted D-dimer and, similar to other posters, the lab result reported does not have the age adjustment in the reference ranges, you have to do it yourself.

 

[migm]

i use it, but they usually get a ct when admitted "positive d-dimer"..

 

[southerndoc]

Had a lady with chest pain a few months ago who had a D-dimer of 290. Our cutoff is <243 (although for some reason, it says <150 is normal somewhere but >243 is the cutoff for abnormal). At any rate, I age adjusted her. The hospitalist ordered a CTA after discussing with him about admitting her for serial cardiac markers. He didn't give any pushback and didn't even tell me he ordered it. Just slid it in under the radar probably as I was on the phone with him.

I was very surprised when the radiologist called me a little later to tell me she had an aortic intramural hematoma with a 5 cm aneurysm.

I guess technically she didn't have a PE.

I still use age-adjusted D-dimer, but it makes me have second thoughts about that n=1 patient. 🙂

 

[BAM!]

Our lab uses the adjusted d-dimer for its normal ranges.

 

[thegenius]

Straight copy/pasted from my autotext treasure chest:

A d-dimer was ordered, which is only very marginally positive at a value of [ ]. When adjusted for the patient's age (Douma et al, JAMA - 2014), this value would be within the normal limits. This practice has been accepted by the American College of Physicians as a "clinical best policy practice" (Ann Inn Med. 2015 Nov 3 - available at ncbi.nlm.nih.cov/pubmed/26414967)

I'm copying / pasting this into my EMR, and will put "per Dr. RustedFox" at the end of it. 🙂

Looks like age-adjusted d-dimer is prime time now, right?

 

[thegenius]

i use it, but they usually get a ct when admitted "positive d-dimer"..

Yup...so sad. They usually get CT Angio for PE even with a negative d-dimer. Our hospitalists test like there is no tomorrow. Very sad.

 

[Fox800]

"The patient the patient is low/medium risk by Wells PE criteria, and has a D-dimer that is considered within normal limits by the age-adjusted D-dimer criteria endorsed by clinical policies of the American College of Emergency Physicians and the American Academy of Emergency Medicine (D-dimer less than age x10 micrograms/L for patients age >50)."

 

[Zebra Hunter]

I use it, just make sure you are using the appropriate cutoff for the assay you have.

For the type using a normal cutoff of 0.5 (FEU), each additional year after 50 adds 0.01 to the age adjusted cut-off.
The assay using 0.23-0.25 as their normal cutoff (DDU) increases 0.005 for each additional year over 50.

 

[Groove]

I haven't really incorporated it into my practice though I admit that the evidence looks solid. I don't find myself playing the dimer roulette game with older patients as often as in times past. I'll either spin them up or I won't and will document my MDM justifying my decision making. I rely on gestalt a lot more at this point and find it tedious to spend so much energy justifying an "abnormal" value on a test that I had 95% certainty would be elevated when I ordered it. I guess it would annoy me less if the hospital and lab was on board with the cut offs and it was an entrenched regional standard of practice. That way I'm not stuck spending so much time in my chart justifying why my 85yo grandma with a dimer of 840 doesn't have a PE after the nurse just documented that she alerted me about the "critical result". I've also gotten a bit paranoid over the years after finding some PEs on the most unlikely of people. I just rarely order them on old people.

 

[RustedFox]

I haven't really incorporated it into my practice though I admit that the evidence looks solid. I don't find myself playing the dimer roulette game with older patients as often as in times past. I'll either spin them up or I won't and will document my MDM justifying my decision making. I rely on gestalt a lot more at this point and find it tedious to spend so much energy justifying an "abnormal" value on a test that I had 95% certainty would be elevated when I ordered it. I guess it would annoy me less if the hospital and lab was on board with the cut offs and it was an entrenched regional standard of practice. That way I'm not stuck spending so much time in my chart justifying why my 85yo grandma with a dimer of 840 doesn't have a PE after the nurse just documented that she alerted me about the "critical result". I've also gotten a bit paranoid over the years after finding some PEs on the most unlikely of people. I just rarely order them on old people.

I dig what you're saying, but here on the gulf coast of Florida (a.k.a. - the "United States Capitol of Old People) this is a huge practice-changer.

My average patient is a 72 year old female.
The "Young Ones" are 55, and are retiring early.

 

[DoctorMedic]

ACEP says it's ok so I do it.

ACEP Clinical Policy on Acute VTE 2018 - REBEL EM - Emergency Medicine Blog

The ACEP policy subcommittee just published a 2018 venous thromboembolism clinical policy. This 51 page document reviews the evidence on five critical questions which we will review in this post.

rebelem.com

 

[Tiger26]

Once it made it into the ACEP guidelines, I got on board and have been using it

 

[thegenius]

That is great I’m going to try to incorporate that more.

 

[DoctorMedic]

Big thing is know if your shop uses DDU or not, DDU = Age x 5, other is Age x 10

 

[deleted109597]

I do whatever helps me sleep at night.

 

[MechEDoc]

That's how I feel. But apparently nobody else I work with agrees. They throw out words like "local standard of care" that makes me feel like a rebel for even bringing up age adjusted cutoffs. In other words, the docs acknowledge the utility but just don't want to practice this way unless everybody else does it here.

Local standard of care isn't the standard of care. However, it can still bite you...

If something bad goes down and people lawyer up, then you'll get a chance to fly in your experts for the medmal deposition.

However, if something only sort of bad goes down and you're sent to peer review, then the local standard of care might matter (depending on how the review panel is stacked), then you might have an adverse finding and be reported to the NPDB. Ugh. Now the local *****s who haven't read a journal in 20 years are setting the "standard of care".

Here's my view on CT PE, d-dimer, etc... We pan scan traumas all the time based upon mechanism. I sleep pretty well after sending home a nicely tenderized trauma patient with a negative full workup (labs, +/- EKG, pan scan).

For a relatively normal person* who shows up unannounced at age 65 with typical American protoplasm (BMI 30, former smoker with 10 pack year history, semi-managed HTN, HLD, and metabolic syndrome) with new onset poorly characterized chest symptoms, why shouldn't I obtain angiography? One quick scan will usually rule in or out PE, dissection, effusions, pneumonia, pneumonitis, etc. The downside for me is a slightly longer dispo. There is a little most cost (not paid by me), lower liability for me and very little increased risk for the patient (ionizing radiation - not so much at age 65, contrast induced nephropathy, usually not an issue, might be a myth). Besides, if I'm running serial troponins, the scan probably won't change disposition time. Sure, one could turf the issue to the admitting physician (if the patient is admitted), but we've all heard about the cases where the PE / dissection is missed and the patient makes it through their stress test, etc. and there is a lawsuit. You can be darn sure you'll be named along with everyone else on the chart.

This doesn't mean I scan ever chest pain, but I'm much more comfortable scanning at a lower threshold than I was before. Positive d-dimer? If I dont' want to scan, then chart why, note age adjustment and dispo. Want to scan? POSITIVE d-dimer -> SCAN!!!

* I.e. not the frequently flier, anxious, personality disorder, etc, etc.

 

[southerndoc]

Why would you be reported to the NPDB? That's only if you have something done that restricts your privileges for more than 30 days according to Title IV.

Section 1921 mentions peer review organizations, but hospital peer review committees are not independent organizations and thus are not reportable unless Title IV applies.

 

[deleted109597]

Ha. I love peer review.
I always come with articles.
I got called into peer review for giving TXA in trauma once. Merely because I was the first person to ever do it at the hospital. CRASH-2 had been out awhile.

 

[thegenius]

Here's my view on CT PE, d-dimer, etc... We pan scan traumas all the time based upon mechanism. I sleep pretty well after sending home a nicely tenderized trauma patient with a negative full workup (labs, +/- EKG, pan scan).

Just remember that there isn't a simple blood test that can exclude the existence of trauma with ~99% certainty. If there was, we would be doing less pan scans.

I get your point for what you are trying to say though. Problem is we over scan traumas as well. We overdo everything in ER and in medicine for a variety of reasons, some we have an easy time controlling and some not.

My attending in residency once said to me, when I recommended we NOT scan a head in someone with minor head trauma:
"Imagine you could theoretically lift the scalp and skull off him to see if he had intracranial bleeding, then put it back on without any consequences to the patient. Wouldn't you want that?"

These kinds of discussions really just come down to how much risk people are willing to take. When it gets quite excessive though with respect to the amount of testing to cover our butts, government and insurance companies notice it and start instituting oversight with MIPS and PQRS and advanced imaging clinical decision support software, or deny payments because a test wasn't justified.

 

[BoardingDoc]

My attending in residency once said to me, when I recommended we NOT scan a head in someone with minor head trauma:
"Imagine you could theoretically lift the scalp and skull off him to see if he had intracranial bleeding, then put it back on without any consequences to the patient. Wouldn't you want that?"

To which I hope you responded: "yes, but that isn't an option, which is why I'm recommending that we not needlessly irradiate this patient"

 

[Groove]

If TORT reform and physician protection from frivolous lawsuits was as much of a priority in this country as reducing healthcare costs by overtesting, then you'd see a lot less CT scans and other tests. Until that happens though, defensive medicine is here to stay. These tests may be expensive, but they are FAST with little lifetime risk in the grand scheme of things and enable comprehensive evaluation and rule out for multiple emergent conditions. They also enable lightning fast dispositions when you can get them done in a timely fashion.

Honestly, I'm probably in the top 20% in CT utilization among the docs in my group. But....I have one of the fastest dispo times on both admissions and discharges. I also have by far the fewest bouncebacks of anyone in the group. As much as I hate saying it...sometimes its just easier to scan and be done with it. Especially for the pt's that aren't going to be satisfied without imaging.

 

[deleted859535]

As much as I hate saying it...sometimes its just easier to scan and be done with it. Especially for the pt's that aren't going to be satisfied without imaging.

Definitely this. Related: too bad I don't care enough to do a little study to see how much our own residents' opinions on such matters change after they've been the attending for a little while.