ABSTRACT
Background
Guidelines recommend therapeutic anticoagulation for select patients with suspected pulmonary embolism (PE) while awaiting confirmatory imaging. International practice regarding preemptive anticoagulation in the emergency department (ED) is not well understood. We aimed to describe emergency physician use of preemptive anticoagulation in patients with suspected PE and identify characteristics associated with its use.
Methods
We conducted an international survey of emergency physicians. The survey was distributed between November 2024 and May 2025. Physicians were asked about use of preemptive anticoagulation, factors associated with use, knowledge of international guidelines, and availability of local protocols. A clinical vignette examined decision making surrounding initiation of preemptive anticoagulation. Multivariable logistic regression models were used to examine factors associated with (1) sometimes/always using preemptive anticoagulation and (2) with use in the vignette.
Results
There were 413 responses (27.6% response rate) from 13 countries. Among respondents, 23.1% reported never providing preemptive anticoagulation, 73.9% reported sometimes using it, and 2.9% reported always using it. Over two‐thirds of respondents were unaware of recommendations for using preemptive anticoagulation and half reported their institution did not have protocols for preemptive anticoagulation. In multivariable regression, more clinical experience (OR: 1.81, 95% CI: 1.38–2.38), higher self‐rated knowledge about PE (OR: 2.05, 95% CI: 1.03–4.06), and more concern for cardiovascular deterioration (OR: 3.21, 95% CI: 1.88–5.49) were positively associated with sometimes/always using preemptive anticoagulation. More concern for bleeding was associated with a lower odds of sometimes or always using preemptive anticoagulation. In the vignette, respondents with institutional protocols for preemptive anticoagulation had higher odds of starting preemptive anticoagulation and those with more concern for bleeding had lower odds of starting it.
Conclusion
Use of preemptive anticoagulation for patients with suspected PE was low. Most physicians were unaware of guidelines supporting its use and do not have institutional protocols to guide use of preemptive anticoagulation. Implementation and use of institutional protocols may increase guideline‐directed preemptive anticoagulation in select patients.
Keywords: anticoagulation, emergency medicine, pulmonary embolism
1. Introduction
Pulmonary embolism (PE) is a serious and potentially life‐threatening disease [1]. Many emergency department (ED) patients present with symptoms that may reflect underlying PE [2]. PE is most commonly diagnosed with computed tomography angiography (CTA) imaging. PE is treated with therapeutic anticoagulation with low‐molecular weight heparin, intravenous unfractionated heparin, or direct oral anticoagulants [1].
International society guidelines, such as the American College of Chest Physicians (CHEST), American Heart Association (AHA), European Society of Cardiology (ESC), the National Institute for Health and Care Excellence (NICE), and the PERT Consortium recommend the use of validated pre‐test probability scores such as the Wells' or Geneva score to risk stratify patients into low, intermediate and high pre‐test probability of PE [3, 4]. Several of these guidelines recommend that patients with intermediate to high pre‐test probability of PE should receive immediate therapeutic anticoagulation while awaiting confirmatory imaging for PE [4]. Specifically, the ESC and AHA recommend initiating therapeutic anticoagulation for patients with an intermediate and high pre‐test probability of PE while awaiting confirmatory imaging if there are no contraindications to anticoagulation [3, 5, 6]. The PERT Consortium recommends immediate therapeutic anticoagulation in patients with a high pre‐test probability of PE, if bleeding risk is low [7]. CHEST recommends immediate preemptive anticoagulation for patients with high pre‐test probability while awaiting diagnostic imaging, for those with intermediate pre‐test probability if imaging results are expected to be delayed for more than 4 h, and for those with low pre‐test probability if imaging results are expected to be delayed for more than 24 h [8]. NICE recommends that therapeutic anticoagulation should be initiated in all patients with suspected PE if results of confirmatory diagnostics will take longer than 4 h [4, 9].
Delays to therapeutic anticoagulation in patients with confirmed PE has been associated with increased morbidity and mortality [10, 11]. Thus, the rationale for preemptive anticoagulation while awaiting diagnostic testing is to reduce treatment delays in patients ultimately diagnosed with PE [12]. Although pre‐diagnostic anticoagulation exposes patients to risk of hemorrhage, this risk is very low [13]. There are, however, no randomized clinical trials evaluating the risk–benefit ratio of preemptive anticoagulation. In a decision analysis study, preemptive anticoagulation was superior to no treatment when the delay to diagnosis was more than 2.3 h for patients at intermediate pre‐test probability of PE and more than 20 min for patients at high pre‐test probability based on the revised Geneva score. Using the two‐tier Wells' score, preemptive anticoagulation was superior for patients at PE‐likely probability if delay to diagnosis was greater than 1.7 h [14]. Preemptive anticoagulation could theoretically prevent 166 deaths out of 100,000 patients with a high pre‐test probability based on the revised Geneva score with a 12‐h delay until diagnosis [14].
Delays to initiation of anticoagulation are particularly relevant in the ED setting where wait times for assessment and diagnostic testing can be hours [15, 16, 17]. Despite several guidelines suggesting preemptive anticoagulation for patients with intermediate‐to‐high pre‐test probability of PE, small studies have found the use of preemptive anticoagulation is uncommon in ED patients evaluated for PE [12, 15, 18, 19], even among patients with a high pre‐test probability of PE [12]. However, such studies have not explored factors associated with emergency physicians' decision to use preemptive anticoagulation. Therefore, the aim of this study was to describe emergency physician use of preemptive anticoagulation in patients with suspected PE, and identify physician and environmental characteristics associated with its use.
2. Methods
2.1. Study Design and Population
This cross‐section, international, online survey was distributed to faculty emergency physicians working in one of 37 participating EDs. Participating EDs were identified through contacts in the Emergency Advisory and Research International Board on Thrombosis (EARTH) research group. These EDs spanned 5 continents and 13 countries (Australia, Canada, Denmark, France, Hong Kong, Israel, Italy, Singapore, South Africa, Spain, Switzerland, United Kingdom [UK] and the United States). Ethics approval for this study was obtained from the Research Ethics Board at Sinai Health in Ontario, Canada. This study followed the CROSS checklist for reporting results of survey studies [20, 21].
2.2. Survey Development
The initial survey was developed by three emergency physician researchers (KG, SDC, OH) who are members of EARTH. The survey was pilot tested with five emergency physicians to assess comprehension and construct validity and revised based on feedback (see Supporting Information for the final version of the survey). Survey questions focused on respondents' demographics, self‐rated knowledge of PE rated on a 6‐point Likert scale (1 = not knowledgeable at all to 6 = very knowledgeable), self‐reported use of preemptive anticoagulation for suspected PE categorized as “always,” “sometimes,” and “never,” factors associated with use of preemptive anticoagulation, local institutional protocols for the use of preemptive anticoagulation, and knowledge of relevant international society recommendations and/or guidelines. Respondents were asked to rate their general concern for cardiorespiratory deterioration and risk of bleeding on a 6‐point Likert scale (1 = not concerned to 6 = very concerned) when considering preemptive anticoagulation. These responses were dichotomized into low (1–3 on the Likert scale) versus high concern (4–6 on the Likert scale).
Finally, a clinical vignette describing a patient with intermediate‐to‐high pre‐test probability of PE and a low bleeding risk was presented and respondents were asked whether they would start anticoagulation. The vignette stated “A 34‐year‐old obese female who takes estrogen‐containing contraceptives presents with acute shortness of breath and unilateral leg swelling. Her vital signs are: heart rate: 125 beats per minute; respiratory rate: 24 breaths per minute; oxygen saturation: 92%; blood pressure: 102/70 mmHg; temperature: 97.8°F (36.6°C)”. Respondents were asked to assume CT angiography of the chest could be completed within 1 h.
2.3. Data Collection
The survey was electronically distributed to participating EDs between November 2024 and May 2025. The survey and data were housed on a secure web‐based survey software (Qualtrics, Provo, UT). A site representative at each participating ED was sent a survey link by email which was then distributed locally to all emergency physicians at that site. The site representative reported how many physicians received the survey to facilitate response rate calculation. Completion of the survey was voluntary. No incentives were provided to participants. Responses were anonymous.
2.4. Data Analysis
We calculated the response rate using the number of responses from each ED with the number of physicians who received the survey at each site. Three participating EDs did not report the number of physicians who received the survey. We imputed this number based on the median number of physicians receiving the survey across the other EDs. Descriptive statistics with frequencies and proportions were used to analyze responses to survey questions. Multivariable logistic regression using a generalized estimating equation to account for clustering by country was used to identify factors associated with sometimes or always using preemptive anticoagulation compared to never using it. We included six physician and environmental covariates in the model that were chosen a priori: respondent gender, years of experience, self‐rated knowledge of PE, concern for bleeding, concern for cardiorespiratory deterioration, and institutional protocols for the use of preemptive anticoagulation. A second logistic regression model was used to identify factors associated with starting preemptive anticoagulation in the clinical vignette and included the same covariates above. Odds ratios (ORs) with 95% confidence intervals (CIs) were reported. Data analysis was performed using R version 4.4.2 (R Core Team, Vienna).
3. Results
The overall response rate was 27.6% (413/1498), with 39.0% female respondents, 51.1% practicing in a university‐affiliated hospital ED, and 51.8% with less than 10 years of emergency medicine experience. Approximately 95% of respondents considered themselves to be knowledgeable about PE, rating their knowledge between 4 to 6 on a 6‐point Likert scale. Over two‐thirds of respondents (69.5%, 287/413) were unaware of evidence or recommendations for the use of preemptive anticoagulation in patients with suspected PE. Over half of respondents (56.7%) reported that their institution did not have a protocol for preemptive anticoagulation and 29.1% did not know if their institution had a protocol. See Table 1 for demographics of respondents and survey responses.
TABLE 1.
Respondent characteristics and survey responses.
| Total (N = 413) | Do you provide preemptive anticoagulation for suspected PE? | ||
|---|---|---|---|
| Never (n = 96) | Sometimes/always (n = 317) | ||
| Age (median, IQR) | 40.0 (34.0–49.0) | 38.0 (33.0–43.0) | 40.0 (34.8–49.0) |
| Experience, n (%) | |||
| < 10 years | 214 (51.8) | 59 (61.5) | 155 (48.9) |
| 10+ years | 193 (46.7) | 36 (37.5) | 157 (49.5) |
| Missing | 6 (1.5) | 1 (1.0) | 5 (1.6) |
| Gender, n (%) | |||
| Female | 161 (39.0) | 34 (35.4) | 127 (40.1) |
| Male | 244 (59.1) | 59 (61.5) | 185 (58.4) |
| Other/prefer not to say | 8 (1.9) | 3 (3.1) | 5 (1.6) |
| Knowledgeable about PE, n (%) | |||
| No (1–3 on Likert scale) | 21 (5.1) | 8 (8.3) | 13 (4.1) |
| Yes (4–6 on Likert scale) | 392 (94.9) | 88 (91.7) | 304 (95.9) |
| Institutional protocols, n (%) | |||
| No/don't know | 354 (85.7) | 88 (91.7) | 266 (83.9) |
| Yes | 59 (14.3) | 8 (8.3) | 51 (16.1) |
| University affiliation, n (%) | |||
| No | 200 (48.4) | 51 (53.1) | 149 (47.0) |
| Yes | 211 (51.1) | 45 (46.9) | 166 (52.4) |
| Missing | 2 (0.5) | 0 (0) | 2 (0.6) |
| Concern for bleeding, n (%) | |||
| Low (1–3 on Likert scale) | 251 (60.8) | 46 (47.9) | 205 (64.7) |
| High (4–6 on Likert scale) | 158 (38.3) | 47 (49.0) | 111 (35.0) |
| Missing | 4 (1.0) | 3 (3.1) | 1 (0.3) |
| Concern for cardiorespiratory deterioration, n (%) | |||
| Low (1–3 on Likert scale) | 164 (39.7) | 56 (58.3) | 108 (34.1) |
| High (4–6 on Likert scale) | 247 (59.8) | 38 (39.6) | 209 (65.9) |
| Missing | 2 (0.5) | 2 (2.1) | 0 (0) |
| Country, n (%) | |||
| Australia | 50 (12.1) | 9 (9.4) | 41 (12.9) |
| Canada | 69 (16.7) | 14 (14.6) | 55 (17.4) |
| Denmark | 9 (2.2) | 2 (2.1) | 7 (2.2) |
| France | 52 (12.6) | 12 (12.5) | 40 (12.6) |
| Israel | 15 (3.6) | 7 (7.3) | 8 (2.5) |
| Switzerland | 112 (27.1) | 20 (20.8) | 92 (29.0) |
| United Kingdom | 11 (2.7) | 0 (0) | 11 (3.5) |
| United States | 86 (20.8) | 31 (32.3) | 55 (17.4) |
| Countries with < 5 responses (Hong Kong, Italy, Singapore, Spain, South Africa), N (%) | 9 (2.2) | 1 (1.0) | 8 (2.5) |
| Vignette response, n (%) | |||
| Did not start preemptive anticoagulation | 218 (52.8) | 64 (66.7) | 154 (48.9) |
| Started preemptive anticoagulation | 151 (36.6) | 18 (18.9) | 133 (42.0) |
| Missing | 44 (10.7) | 4 (4.2) | 30 (9.5) |
Abbreviations: IQR, interquartile range; PE, pulmonary embolism; SD, standard deviation.
Only 2.9% (12/413) of respondents reported always using preemptive anticoagulation, 73.8% (305/413) reported using preemptive anticoagulation sometimes, and 23.2% (96/413) reported never using it. Among those who reported sometimes using preemptive anticoagulation, the majority (75.7%) reported using it in less than 20% of patients with suspected PE. The proportion of respondents who used preemptive anticoagulation differed between countries, with a larger proportion of respondents from the UK always using it and a larger proportion of respondents from Israel and the United States never using it (Table 1 and Figure 1).
FIGURE 1.
Responses by country to the question, “Do you provide preemptive anticoagulation for patients with suspected PE in the emergency department?”
When considering physician concerns regarding the use of preemptive anticoagulation for suspected PE, 29.1% (120/413) of respondents were equally concerned about cardiorespiratory deterioration and risk of bleeding. However, 50.1% (207/413) were more concerned with cardiorespiratory deterioration and 19.9% (82/413) were more concerned with bleeding (Figure 2).
FIGURE 2.
Heat map displaying concern for cardiorespiratory deterioration vs. bleeding when considering preemptive anticoagulation.
Half of respondents (50%, 6/12) who reported always using preemptive anticoagulation did so based on institutional protocols. Among respondents who always or sometimes used preemptive anticoagulation, the most common factors that guided their decision included: abnormal vital signs (77.9%, 247/317), delays to imaging tests (76.3%, 242/317), laboratory values and clinical signs suggesting patients at intermediate or high risk of clinical deterioration (72.9%, 231/317), and patients at intermediate or high pre‐test probability of PE by prediction rule or gestalt (55.5%, 176/317). When asked which factors influence their decision to withhold preemptive anticoagulation the most common factors were: high risk of bleeding (79.2%, 327/413), the need for blood work prior to preemptive anticoagulation (27.8%, 115/413), and the risk of heparin‐induced thrombocytopenia (25.2%, 104/413). Among respondents who chose high risk of bleeding as a factor influencing their decision to withhold preemptive anticoagulation, 51.7% responded they determine patients' risk of bleeding by gestalt, whereas 46.8% used a prediction tool.
In the multivariable logistic regression, respondents with more years of clinical experience (OR: 1.81, 95% CI: 1.38–2.38), those who considered themselves more knowledgeable about PE (OR: 2.05, 95% CI: 1.03–4.06), and those with higher levels of concern for cardiovascular deterioration (OR: 3.21, 95% CI: 1.88–5.49) had significantly higher odds of sometimes or always using preemptive anticoagulation. Conversely, those who had higher levels of concern for bleeding were significantly less likely to sometimes or always use preemptive anticoagulation (OR: 0.48, 95% CI: 0.30–0.76) (Table 2).
TABLE 2.
Adjusted odds of sometimes or always using preemptive anticoagulation in patients with suspected PE in the ED.
| Variable | Adjusted Odds Ratio (95% confidence interval) |
|---|---|
| Experience | |
| < 10 years | Ref |
| ≥ 10 years | 1.81 (1.38–2.38) |
| Physician gender | |
| Female | Ref |
| Male | 0.79 (0.46–1.31) |
| Knowledgeable about PE | |
| Low (1–3 on Likert scale) | Ref |
| High (4–6 on Likert scale) | 2.05 (1.03–4.06) |
| Institutional protocols | |
| No/don't know | Ref |
| Yes | 1.50 (0.82–2.72) |
| Concern for bleeding | |
| Low (1–3 on Likert scale) | Ref |
| High (4–6 on Likert scale) | 0.48 (0.30–0.76) |
| Concern for cardiorespiratory deterioration | |
| Low (1–3 on Likert scale) | Ref |
| High (4–6 on Likert scale) | 3.21 (1.88–5.49) |
Of the 413 respondents, 369 (89.3%) responded to the clinical vignette with 151 (40.9%) indicating that they would start preemptive anticoagulation. In the multivariable logistic regression examining factors associated with starting preemptive anticoagulation in the vignette, we found that respondents who had institutional protocols for the use of preemptive anticoagulation had significantly higher odds of starting preemptive anticoagulation (OR: 2.34, 95% CI: 1.36–4.04) and those with higher concerns of bleeding had lower odds of starting preemptive anticoagulation (OR: 0.57, 95% CI: 0.41–0.79) (Table 3).
TABLE 3.
Adjusted odds of initiating preemptive anticoagulation in the clinical vignette.
| Variable | Adjusted Odds Ratio (95% confidence interval) |
|---|---|
| Experience | |
| < 10 years | Ref |
| ≥ 10 years | 0.92 (0.57–1.50) |
| Physician gender | |
| Female | Ref |
| Male | 1.02 (0.70–1.50) |
| Knowledgeable about PE | |
| Low (1–3 on Likert scale) | Ref |
| High (4–6 on Likert scale) | 1.56 (0.75–3.27) |
| Institutional protocols | |
| No/don't know | Ref |
| Yes | 2.34 (1.36–4.04) |
| Concern for bleeding | |
| Low (1–3 on Likert scale) | Ref |
| High (4–6 on Likert scale) | 0.57 (0.41–0.79) |
| Concern for cardiorespiratory deterioration | |
| Low (1–3 on Likert scale) | Ref |
| High (4–6 on Likert scale) | 1.32 (0.67–2.61) |
4. Discussion
We surveyed emergency physicians on their use of preemptive anticoagulation for patients with suspected PE in the ED. Overall, there was low reported use of preemptive anticoagulation, with almost a quarter of respondents never providing preemptive anticoagulation. Previous studies of patients undergoing diagnostic work‐up of PE in the ED have reported anywhere from 0.6% to 7.4% of patients receive preemptive anticoagulation [15, 18, 19]. In our study, when we asked participants how often they use preemptive anticoagulation, years of clinical experience, high concern for cardiorespiratory deterioration, and being knowledgeable about PE were independently associated with always or sometimes using preemptive anticoagulation, while high concern for bleeding was associated with never using preemptive anticoagulation. In contrast, when we presented a clinical vignette, only knowledge of an institutional protocol for preemptive anticoagulation was associated with giving preemptive anticoagulation, while high concern for bleeding was negatively associated with preemptive anticoagulation in the clinical vignette.
There were variations in practice by country, with a larger proportion of respondents from the UK always providing preemptive anticoagulation and a larger proportion of respondents from Israel and the United States never providing it. Among respondents who reported always using preemptive anticoagulation, the most commonly selected reason to do so was because of an institutional protocol. We found awareness of an institutional protocol advising preemptive anticoagulation was associated with preemptive anticoagulation in the clinical vignette. The UK NICE guidelines advise all patients tested for PE receive preemptive anticoagulation if there is an expected delay of 4 h or longer until testing results are available [9]. Other guidelines do not advise preemptive anticoagulation regardless of pre‐test probability of PE. This may explain some of the variation observed by country and suggests that when guidelines are translated into institutional protocols [22], they may be effective in changing local culture and practice norms. Other regional differences to explain why respondents from Israel and the United States are less likely to provide preemptive anticoagulation compared to the UK need to be further explored. Some of this variation may be a result of differences in these countries' health systems, such as levels of ED crowding, access and availability to imaging, and variations in practice within each country itself.
In this study, a larger proportion of respondents were more concerned with the risk for cardiorespiratory deterioration than bleeding in the context of preemptive anticoagulation. However, higher concern for bleeding was significantly associated with never giving preemptive anticoagulation as well as withholding preemptive anticoagulation in the clinical vignette case. In contrast, although high concern for cardiorespiratory deterioration was associated with always or sometimes providing preemptive anticoagulation, it was not significantly associated with giving preemptive anticoagulation in the clinical vignette. This suggests concern for bleeding may be a stronger barrier to preemptive anticoagulation use in clinical practice. While the majority of respondents considered themselves knowledgeable about PE, 25.2% of respondents cited fear of causing heparin‐induced thrombocytopenia as influencing their decision to withhold preemptive anticoagulation. However, the risk of heparin‐induced thrombocytopenia is exceptionally low (< 1%) [23] with contemporary heparins and avoided with direct oral anticoagulants. Prior PE research has identified local culture and fear as a strong practice influencer [24]. We do not know whether participant concerns about cardiorespiratory deterioration or bleeding in our study are based on real‐life estimates of risk, or whether education on contemporary risks would change perceived risks and preemptive anticoagulation decision making.
Decision analyses suggest that preemptive anticoagulation could prevent death from PE [14]. Our results found that effective implementation of local protocols may help increase the rate of preemptive anticoagulation for emergency patients being tested for PE. While it is recognized that changing physician clinical practice and behaviors is multi‐dimensional [25], several studies have shown improvement in guideline‐directed care following implementation of institutional protocols [22]. Best evidence suggests that protocol implementation should include multiple approaches tailored to the local environment, such as local champions, simplifying the intervention, repeated education, and audit and feedback [26].
Future research should address the major barrier of lack of robust evidence of a favorable risk–benefit ratio with preemptive anticoagulation. Given the small absolute number of prevented deaths (166 out of 100,000 patients with high pre‐test probability) [14], randomized studies may not be feasible, but large cohort studies adjusting for confounding could provide a higher level of evidence than currently exists. Future studies are needed that examine interventions to increase uptake of guideline recommendations for preemptive anticoagulation in patients with suspected PE, particularly in high‐risk patients. Future research to better understand other individual‐ and institutional‐level barriers to using preemptive anticoagulation is also needed, which may include costs, logistical issues, availability of imaging, local practice culture, and individual physician traits/characteristics.
Our study has several limitations. This was a survey based on self‐reported data, which may result in observer bias with responses that do not accurately reflect respondents' actual practice. Physicians tend to overestimate their performance compared to actual practice [27]. However, our reported use of preemptive anticoagulation was low and comparable to other studies based on chart review that report rates between 0.6% and 7.4%. Participation in the study was voluntary and our response rate was in the lower range [28]. This rate is consistent with other studies using survey methodology, including surveys of physicians [29, 30]; however, there may be nonresponse bias where respondents may differ from nonrespondents regarding familiarity with PE management. Studies comparing respondents with the full sample in physician surveys have shown that while respondents often differ from nonrespondents, these differences usually translate into only small deviations in outcome estimates [31, 32, 33]. Finally, given the variable number of responses by country, we were unable to fully examine country‐specific variations in practice.
5. Conclusion
In this international survey, emergency physicians reported low overall use of preemptive anticoagulation for patients with suspected PE. Most physicians were unaware of guidelines supporting the use of preemptive anticoagulation while awaiting confirmatory testing, and most did not have institutional protocols to guide the use of preemptive anticoagulation in ED patients with suspected PE. Implementation and use of institutional protocols may increase guideline‐directed use of preemptive anticoagulation in select patients.
Author Contributions
K.G., S.D.C., O.H. were involved in study conceptualization. K.G., W.B.S., S.D.C., O.H., K.W. developed and revised the survey. K.G., C.T. conducted the analyses. All authors contributed to data interpretation. K.G. prepared the first draft of the manuscript and all authors edited and provided critical feedback and approved the final manuscript.
Funding
The authors have nothing to report.
Conflicts of Interest
The authors declare no conflicts of interest.
Supporting information
Data S1: Preemptive anticoagulation survey.
Grewal K., Stubblefield W. B., Casey S. D., et al., “Preemptive Anticoagulation for Patients With Suspected Pulmonary Embolism in the Emergency Department: An International Survey of Emergency Physicians,” Academic Emergency Medicine 33, no. 4 (2026): e70297, 10.1111/acem.70297.
Supervising Editor: Brandon C. Maughan
Data Availability Statement
Aggregated data that support the findings of this study may be available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data S1: Preemptive anticoagulation survey.
Data Availability Statement
Aggregated data that support the findings of this study may be available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.