Patient values and preferences in pulmonary embolism testing in the emergency department

Abstract

Introduction:Patient-centered care is concordant with patient values and preferences. There is a lack of research on patient values and preferences for pulmonary embolism (PE) testing in the emergency department (ED), and a poor physician understanding of patient-specific goals. Our aim was to map patient-specific values, preferences, and expectations regarding PE testing in the ED.Method: This qualitative study used constructivist grounded theory to identify patient values and expectations around PE testing in the ED. We conducted semistructured interviews with ED patients who were being tested for PE in two EDs.Patients who were waiting for PE imaging or D-dimer results were approached and consented to take part in a 30-minute audio-recorded interview. Each interview was transcribed verbatim and analyzed using constant comparative coding. The interview script was modified to maximize information on emerging themes. Major themes and subthemes were derived, each representing an opportunity, barrier, or value to address with patient-centered PE testing.Results: From 30 patient interviews, we mapped four major themes: patient satisfaction comes from addressing the patient's primary concern (for example, their pain); patients expect individualized care; patients prefer imaging over clinical examination for PE testing; and patients expect 100% confidence from their emergency physician when given a diagnosis. Subthemes included symptomatic relief, finding a diagnosis, receiving tests, rapid progression through their care, perception of highly accurate CT scans, willingness to seek a second opinion, direct physician communication, and expectation of case-specific testing with cognitive reassurance. Conclusion:Addressing each of these four themes by realigning ED processes could provide patient-centered PE testing.

Mapping emergency physician reasoning for adhering to evidence‐based pulmonary embolism testing

“…Paradoxically, most participants found the Wells score and D‐dimer to be helpful for their practice. Recent literature suggests patients equate better care with access to additional PE tests, 8 however, our participants were comfortable using the results of the PERC, Wells scores and D‐dimer to explain to patients why they did not need imaging. Instead, lack of adherence to evidence‐based practice seemed to be influenced by nagging doubts, anecdote, severity of the patient illness, fear of missing PE and a “feeling.” All of these components contributed to a Gestalt estimate that the patient could have underlying PE, despite evidence to the contrary.…”