Predictors of Overtesting in Pulmonary Embolism Diagnosis

Abstract

Background: The benefits of computed tomography pulmonary angiography (CTPA) for pulmonary embolism (PE) diagnosis must be weighed against its risks, radiation-induced malignancy, and contrast-induced nephropathy. Appropriate use of CTPA can be assessed by monitoring yield, the percentage of tests positive for PE. We identify factors that are associated low CTPA yield, which may predict overtesting.Methods: This was a retrospective cohort study of six emergency departments between June 2014 and February 2017. The electronic health record was queried for CTPAs ordered for adult patients in the emergency department. We assessed the following patient factors: age, gender, body mass index, number of comorbidities, race, and ethnicity, provider factors: type (resident, fellow, attending, physician assistant) and environment factors: test time of day, season of visit, and crowdedness of the department.Results: A total of 14,782 CTPAs were reviewed, of which 1366 were found to be positive for PE, resulting in an overall CTPA yield of 9.24%. Provider type was not associated with a difference in yield. Testing was less likely to be positive in younger patients, females, those with lower body mass indexes and those identifying as Asian or Hispanic. Testing was also less likely to be positive when ordered during the overnight shift and during the winter and spring seasons. Conclusion:Our study identified several patient and environmental factors associated with low CTPA yield suggesting potential targets for overtesting. Targeting education and clinical decision support to assist providers in these circumstances may meaningfully improve yields.

Chest

“…Knowledge of the presentation and management of acute PE are pertinent to the role of the NP as this condition carries a high risk of mortality (of up to 34%) without timely diagnosis. 26 As signs and symptoms are nonspecifi c, the NP plays a pivotal role in the safety and management of patients with PEs by conducting patient risk assessments, managing medical therapy, and providing patient education. 27 PE management initiatives involving NPs can be highly effective and provide signifi cant clinical and economic benefi ts.…”

Advances in the Management of Acute Venous Thromboembolism and New Therapeutic Agents

“…Indeed, of patients with suspected VTE, only one out of every five patients will have DVT or PE after exhaustive investigations. [21][22][23] The problems with relying on diagnostic imaging in a population with a low to moderate VTE incidence are the associated healthcare costs, exposure to unnecessary radiation and intravenous contrast in many patients undergoing CTPA, frequent false positives, and the diagnosis of events of unclear clinical significance such as subsegmental PE or distal DVT.…”

Influencing factors on the time to CT in suspected pulmonary embolism: an explorative investigation

“…Since its introduction, multiple studies have described an increase in the usage of CTPA accompanied by a decrease in diagnostic yield trends 10 – 12 . Subgroups that were reported to be especially at risk of overutilization of CTPA were young patients and females 13 , in whom the associated increased radiation exposure is particularly critical. The topic becomes even more complex considering that the decline in mortality rates slowed or demonstrated a rebound increase among young and middle-aged adults 7 .…”