Overutilisation of imaging studies for diagnosis of pulmonary embolism: are we following the guidelines?

Dhakal, Prajwal; Iftikhar, Mian Harris; Atti, Varunsiri; Panthi, Sagar; Ling, Xiao; Mujer, Mark; Dawani, Om; Manoj, P; Tatineni, Shilpa; Shrotriya, Shiva; Rayamajhi, Supratik

doi:10.1136/postgradmedj-2018-135995

Cited by 29 publications

(24 citation statements)

References 28 publications

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“…This study identifies an overutilization of CTPA examinations in Edmonton emergency departments, which is congruent with several other studies across the world [4,6,8,10,15,16], most recently shown in a large retrospective cohort out of Michigan in 2018 [17]. We found 26.7% of CTPA studies did not follow a CDM tool, despite evidence and guidelines recommending CDM tools over clinical gestalt [6–8].…”

Section: Discussionsupporting

confidence: 89%

Retrospective Analysis of the Computed Tomography Pulmonary Angiogram Utilization Patterns in the Emergency Department

2019

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Objectives Guidelines and high-quality studies recommend using clinical decision-making (CDM) tools over clinical gestalt when evaluating a patient for pulmonary embolism. The purpose of this study is to investigate our computed tomography pulmonary angiogram (CTPA) utilization patterns and identify causal factors. Methods A retrospective cohort study of CTPA studies ordered by emergency physicians in January, April, July, and October 2017 was undertaken. All necessary information to categorize patients by Wells' score, revised Geneva score, and pulmonary embolism rule-out criteria (PERC) was collected. In addition, various bloodwork, chest radiograph, and computed tomography results were collected. This data was analysed by the Pearson chi-square test or Fisher's exact test for categorical data and independent-samples t test for continuous variables. Results A total of 510 CTPA studies were performed, with a mean age was 61.6 and a 50.6% female population. 136 studies (26.7%) failed to appropriately follow any CDM tool. CDM tool failure rate was dependent on whether the study was ordered from a community (14.9%) or tertiary hospital (University of Alberta Hospital, 27.9% and Royal Alexandra Hospital, 24.6%) ( P = .038). Of these 136 studies, 31 were low/moderate risk and the d-dimer was negative. The remainder were either PERC-negative or low/moderate risk without d-dimer performed. The cumulative positive pulmonary embolism rate was 12.5%. With utilization of a CDM tool, the positive pulmonary embolism rate was 15.0%, compared to 5.9% when using gestalt ( P = .026). Conclusions This study confirms a high rate of CDM tool use failure, and a higher positive CTPA rate for CDM tools compared to clinical gestalt.

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Section: Discussionsupporting

confidence: 89%

Retrospective Analysis of the Computed Tomography Pulmonary Angiogram Utilization Patterns in the Emergency Department

2019

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“…Our study shows that the detection of PE on CTPA in a tertiary care centre in the USA is 10.9% and not as low (<1%) as shown18 in a recent study from a similar tertiary care centre in the USA. The positivity in our study is similar to other previous studies which showed a yield ranging from 6% to 34%, with positivity of 10% or more generally considered acceptable in the USA 19–21.…”

Section: Discussioncontrasting

confidence: 53%

“…An Australasian multicenter trial22 and British Royal College of Radiologists23 have used a cut-off of CTPA positivity greater than 15.4% as a standard-of-care. Most of the studies with less than 10% yield are from the USA,24 with at least two studies showing positivity less than 2% 18 25. This is in contrast to European studies showing a yield well over 10% 26–28.…”

Section: Discussionmentioning

confidence: 93%

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

Aggarwal

Eskandari

Priya

et al. 2020

Postgraduate Medical Journal

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ObjectiveCT pulmonary angiography (CTPA) is one of the most commonly ordered CT imaging tests. It is often believed to be overutilised with few recent studies showing a yield of less than 2%. This study aimed to determine the overall positivity rate of CTPA examinations and understand the factors that affect the yield of the CTPA examination.MethodsWe retrospectively analysed 2713 patients who received the CTPA exam between 2016 and 2018. Type of study ordered (CTPA chest or CTPA chest with abdomen and pelvis CT), patient location (emergency department (ED), outpatient, inpatient, intensive care unit (ICU)) and patient characteristics—age, sex and body mass index (BMI) were recorded. A logistic regression analysis was performed to determine what factors affect the positivity rate of CT scans for pulmonary embolism (PE).ResultsWith 296 positive test results, the overall CTPA positivity was 10.9%. Male sex was associated with higher CTPA positivity, gender difference was maximum in 18-year to 35-year age group. Overweight and obese patients had significantly higher positivity as compared with BMI<25 (p<0.05). Higher positivity rate was seen in the BMI 25–40 group (11.9%) as compared with BMI>40 (10.1%) (p<0.05). Significant difference (p<0.001) was also found in CTPA examination yield from ICU (15.3%) versus inpatients (other than ICU) (12.4%) versus ED (9.6%), and outpatients (8.5%). The difference in CTPA yield based on the type of CT order (CTPA chest vs CTPA chest with CT abdomen and pelvis), patient’s age and sex was not significant.ConclusionCTPA yield of 10.9% in this study is comparable to acceptable positivity rate for the USA and is higher than recent studies showing positivity of <2%. Patient characteristics like obesity and ICU or inpatient location are associated with higher rate of CT positivity.

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“…By continuously monitoring the on-call workload, radiology departments can implement workload-reducing strategies in a timely manner. Medical imaging overutilization is a well-known problem which may have contributed to the increasing on-call workload [18][19][20][21]. Radiologists and radiology departments can play an active role to decrease medical imaging overutilisation by providing education and feedback to referring physicians [22,23].…”

Section: Discussionmentioning

confidence: 99%

Workload for radiologists during on-call hours: dramatic increase in the past 15 years

2020

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Background The objective of this study is to investigate the workload for radiologists during on-call hours and to quantify the 15-year trend in a large general hospital in Western Europe. Methods Data regarding the number of X-ray, ultrasound and computed tomography (CT) studies during on-call hours (weekdays between 6.00 p.m. and 7.00 a.m., weekends, and national holidays) between 2006 and 2020 were extracted from the picture archiving and communication system. All studies were converted into relative value units (RVUs) to estimate the on-call workload. The Mann–Kendall test was performed to assess the temporal trend. Results The total RVUs during on-call hours showed a significant increase between 2006 and 2020 (Kendall's tau-b = 0.657, p = 0.001). The overall workload in terms of RVUs during on-call hours has quadrupled. The number of X-ray studies significantly decreased (Kendall's tau-b = − 0.433, p = 0.026), whereas the number of CT studies significantly increased (Kendall's tau-b = 0.875, p < 0.001) between 2006 and 2020. CT studies which increased by more than 500% between 2006 and 2020 are CT for head trauma, brain CTA, brain CTV, chest CT (for suspected pulmonary embolism), spinal CT, neck CT, pelvic CT, and CT for suspected aortic dissection. The number of ultrasound studies did not change significantly (Kendall's tau-b = 0.202, p = 0.298). Conclusions The workload for radiologists during on-call hours increased dramatically in the past 15 years. The growing amount of CT studies is responsible for this increase. Radiologist and technician workforce should be matched to this ongoing increasing trend to avoid potential burn-out and to maintain quality and safety of radiological care.

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Overutilisation of imaging studies for diagnosis of pulmonary embolism: are we following the guidelines?

Cited by 29 publications

References 28 publications

Retrospective Analysis of the Computed Tomography Pulmonary Angiogram Utilization Patterns in the Emergency Department

Retrospective Analysis of the Computed Tomography Pulmonary Angiogram Utilization Patterns in the Emergency Department

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

Workload for radiologists during on-call hours: dramatic increase in the past 15 years

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