Computed tomography pulmonary angiography is overused to diagnose pulmonary embolism in the emergency department of academic community hospital

Abstract

Background: Pulmonary embolism (PE) is a common disease in the USA responsible for up to 10% of hospital mortality. Modified wells score (MWS) and D-dimer assay are used to categorize patients into high or low probability of PE. Patient with high probability need Computed tomography pulmonary angiography (CTPA), while patients with low probability and low D-dimer can safely forgo the CTPA. Objectives: The aim of this study was to investigate the rate of inappropriate CTPA use in the emergency department of a community teaching hospital. Methods: A retrospective chart review of adult patients who underwent CTPA for suspected PE in the emergency department for 2015 was done. CTPA use was considered inappropriate if MWS was less than or equal to 4 and D-dimer was either not ordered or its value was less than 500 μg/L. Bivariate analysis with Fisher’s exact tests and Student’s t-tests as well as multivariate logistic regression analysis were done to examine relationship between study explanatory variables and study outcome. Results: 295 patients were included in the study. The mean age was 51.2(±14.5) years, 68.8% were females. The prevalence of PE was 5.4% and 41% of the CTPAs -were inappropriately ordered. Males were twice (OR 2.1; 95% CI 1.2, 3.6) as likely as females to have an inappropriately ordered CTPA after controlling for a high MWS, age, and tobacco history. Conclusion: CTPA is overused to diagnose PE in the emergency department. Quality improvement projects are needed to encourage physicians to adhere to the current guidelines.

Pulmonary embolism rule out: positivity and factors affecting the yield of CT angiography

“…While the causes of chest pain can vary, pulmonary embolism (PE) is frequently in the differential diagnosis. PE in itself is one of the leading causes of mortality with estimates suggesting that about 100, 000–2 00, 000 patients die each year from PE 1. When PE is suspected, the current guidelines2 suggest the use of clinical criteria such as the modified Wells score or the modified Geneva score for risk stratification.…”

“…PE in itself is one of the leading causes of mortality with estimates suggesting that about 100, 000–2 00, 000 patients die each year from PE. 1 When PE is suspected, the current guidelines 2 suggest the use of clinical criteria such as the modified Wells score or the modified Geneva score for risk stratification. Diagnostic testing by CT pulmonary angiography (CTPA) or ventilation-perfusion scans is suggested based on clinical presentation, patient symptoms, d-dimer test and pre-test probability.…”

Automated Pulmonary Embolism Risk Classification and Guideline Adherence for Computed Tomography Pulmonary Angiography Ordering

“…Research and quality improvement initiatives in guideline adherence have required labor‐intensive, manual retrospective chart review or prospective data collection . The current national emphasis on reducing inappropriate CTPA imaging in the ED will require widespread and frequent quality assessment and review.…”

Appropriateness of CT pulmonary angiograms according to current diagnostic guidelines based on risk stratification: A retrospective single-center study

“…However, it carries the burden of radiation exposure and the need for using an iodine-based intravenous contrast agent. CTPA is being overused in many departments resulting in clinically non-significant incidental findings, unnecessary follow-ups or contrast-induced nephropathy [5][6][7][8][9][10][11][12][13] . This is why several clinical scoring systems have been developed to identify clinically stable outpatients who have an increased PE risk and may benefit from CTPA, such as the Geneva Score, the Wells Score, and the YEARS Algorithm 14 .…”