{
    "abstract": "Pulmonary embolism (PE) remains a leading cause of maternal mortality, yet diagnosis remains challenging. International diagnostic guidelines vary significantly in their recommendations, making it difficult to determine an optimal policy for evaluation.\nWhich societal-level diagnostic guidelines for evaluation of suspected PE in pregnancy are an optimal policy in terms of its cost-effectiveness?\nWe constructed a complex Markov decision model to evaluate the cost-effectiveness of each identified societal guidelines for diagnosis of PE in pregnancy. Our model accounted for risk stratification, empiric treatment, diagnostic testing strategies, as well as short- and long-term effects from PE, treatment with low-molecular-weight heparin, and radiation exposure from advanced imaging. We considered clinical and cost outcomes of each guideline from a US health care system perspective with a lifetime horizon. Clinical effectiveness and costs were measured in time-discounted quality-adjusted life years (QALYs) and US dollars, respectively. Strategies were compared using the incremental cost-effectiveness ratio (ICER) with a willingness-to-pay threshold of $100,000/QALY. One-way, multiway, and probabilistic sensitivity analyses were performed.\nWe identified six international societal-level guidelines. Base-case analysis showed the guideline proposed by the American Thoracic Society and Society of Thoracic Radiology (ATS-STR) yielded the highest health benefits (22.90 QALYs) and was cost-effective, with an ICER of $7,808 over the guidelines proposed by the Australian Society of Thrombosis and Haemostasis and the Society of Obstetric Medicine of Australia and New Zealand (ASTH-SOMANZ). All remaining guidelines were dominated. The ATS-STR guideline-recommended strategy yielded an expected additional 2.7 QALYs/100 patients evaluated over the ASTH-SOMANZ. Conclusions were robust to sensitivity analyses, with the ATS-STR guidelines optimal in 86%\u00a0of probabilistic sensitivity analysis scenarios.\nThe ATS-STR guidelines for diagnosis of suspected PE in pregnancy are cost-effective and generate better expected health outcomes than guidelines proposed by other medical societies.",
    "authors": [
        {
            "affiliation": "Imaging Clinical Effectiveness and Outcomes Research, Department of Radiology, Northwell Health, Manhasset, NY; Center for Health Innovations and Outcomes Research, The Feinstein Institutes for Medical Research and The Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY; Georgia Institute of Technology, Emory University Hospital, Atlanta, GA.",
            "firstname": "John Austin",
            "initials": "JA",
            "lastname": "McCandlish"
        },
        {
            "affiliation": "Imaging Clinical Effectiveness and Outcomes Research, Department of Radiology, Northwell Health, Manhasset, NY; Center for Health Innovations and Outcomes Research, The Feinstein Institutes for Medical Research and The Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY.",
            "firstname": "Chinara",
            "initials": "C",
            "lastname": "Feizullayeva"
        },
        {
            "affiliation": "Department of Obstetrics and Gynaecology, I.M. Sechenov First Moscow State Medical University, Moscow, Russia; The Institute for Health System Science, The Feinstein Institutes for Medical Research and The Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY; Anticoagulation and Clinical Thrombosis Services, Department of Medicine, Northwell Health at Lenox Hill Hospital, New York, NY.",
            "firstname": "Alex C",
            "initials": "AC",
            "lastname": "Spyropoulos"
        },
        {
            "affiliation": "Department of Radiology and Imaging Science, Emory University Hospital, Atlanta, GA.",
            "firstname": "Paul P",
            "initials": "PP",
            "lastname": "Cronin"
        },
        {
            "affiliation": "Imaging Clinical Effectiveness and Outcomes Research, Department of Radiology, Northwell Health, Manhasset, NY; Radiology, The Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Haifa, Israel.",
            "firstname": "Jason J",
            "initials": "JJ",
            "lastname": "Naidich"
        },
        {
            "affiliation": "Department of Obstetrics and Gynaecology, I.M. Sechenov First Moscow State Medical University, Moscow, Russia; Department of Hematology, Rambam Health Care Campus, Haifa, Israel; The Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel.",
            "firstname": "Benjamin",
            "initials": "B",
            "lastname": "Brenner"
        },
        {
            "affiliation": "Center for Health Innovations and Outcomes Research, The Feinstein Institutes for Medical Research and The Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY.",
            "firstname": "Thomas",
            "initials": "T",
            "lastname": "McGinn"
        },
        {
            "affiliation": "Imaging Clinical Effectiveness and Outcomes Research, Department of Radiology, Northwell Health, Manhasset, NY; Center for Health Innovations and Outcomes Research, The Feinstein Institutes for Medical Research and The Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY.",
            "firstname": "Pina C",
            "initials": "PC",
            "lastname": "Sanelli"
        },
        {
            "affiliation": "Imaging Clinical Effectiveness and Outcomes Research, Department of Radiology, Northwell Health, Manhasset, NY; Center for Health Innovations and Outcomes Research, The Feinstein Institutes for Medical Research and The Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY. Electronic address: slcohen@northwell.edu.",
            "firstname": "Stuart L",
            "initials": "SL",
            "lastname": "Cohen"
        }
    ],
    "conclusions": null,
    "copyrights": "Copyright \u00a9 2022. Published by Elsevier Inc.",
    "doi": "10.1016/j.chest.2021.11.036",
    "journal": "Chest",
    "keywords": [
        "VTE in pregnancy",
        "decision science",
        "health economics outcomes research",
        "imaging"
    ],
    "methods": null,
    "publication_date": "2021-12-17",
    "pubmed_id": "34914975",
    "results": "We identified six international societal-level guidelines. Base-case analysis showed the guideline proposed by the American Thoracic Society and Society of Thoracic Radiology (ATS-STR) yielded the highest health benefits (22.90 QALYs) and was cost-effective, with an ICER of $7,808 over the guidelines proposed by the Australian Society of Thrombosis and Haemostasis and the Society of Obstetric Medicine of Australia and New Zealand (ASTH-SOMANZ). All remaining guidelines were dominated. The ATS-STR guideline-recommended strategy yielded an expected additional 2.7 QALYs/100 patients evaluated over the ASTH-SOMANZ. Conclusions were robust to sensitivity analyses, with the ATS-STR guidelines optimal in 86%\u00a0of probabilistic sensitivity analysis scenarios.",
    "title": "Comparison of Guidelines for Evaluation of Suspected Pulmonary Embolism in Pregnancy: A Cost-effectiveness Analysis.",
    "xml": "<Element 'PubmedArticle' at 0x788503f08540>"
}