Underuse of risk assessment and overuse of computed tomography pulmonary angiography in patients with suspected pulmonary thromboembolism

Perera, Michael; Aggarwal, Leena; Scott, Ian A; Cocks, Nicholas

doi:10.1111/imj.13524

Cited by 30 publications

(34 citation statements)

References 37 publications

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“…Despite numerous guidelines and algorithms that aim to prevent overtesting with CTPA in patients at low risk of PE, there is ample evidence that CTPA is frequently inappropriately ordered ( e.g. without using pre-test clinical probability scores or ignoring evidence of low pre-test probability and/or negative D-dimer tests) [7–10]. There appear to be large variations in overtesting practices between clinicians [11].…”

Section: Overtesting For Pementioning

confidence: 99%

Overdiagnosis of pulmonary embolism: definition, causes and implications

Dobler

2019

Breathe

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Overuse of computed tomography pulmonary angiography to diagnose pulmonary embolism in people who have only a low pre-test probability of pulmonary embolism has received significant attention in the past. The issue of overdiagnosis of pulmonary embolism, a potential consequence of overtesting, has been less explored. The term “overdiagnosis”, used in a narrow sense, describes a correct (true positive) diagnosis in a person but without any associated harm. The aim of this review is to summarise literature on the topic of overdiagnosis of pulmonary embolism and translate this epidemiological concept into the clinical practice of respiratory professionals. The review concludes that the location of pulmonary embolism at a subsegmental level, rather than whether a diagnosis was made incidentally or following an investigation for suspected pulmonary embolism, is the best predictor for situations in which anticoagulation may not be necessary. In the absence of strong evidence of the optimal management of subsegmental pulmonary embolism, treatment decisions should be made case by case, taking into account the patient's situation and preference.Key pointsSince the introduction of computed tomography pulmonary angiography in 1998, there has been a steep increase in the diagnosis of pulmonary embolism (PE).An increased incidence of PE diagnoses, but an almost stable mortality from PE in the population, together with a decreased case fatality, point towards overdiagnosis (in the absence of more effective treatment).Whether PE is diagnosed as an incidental finding or following an investigation for suspected PE does not appear to influence the need for anticoagulation therapy.An isolated subsegmental PE may not require anticoagulation therapy, and treatment decisions should be made case by case, taking into account the patient's situation and preference.A suggested definition of overdiagnosis of PE: a diagnosis of PE that, if left untreated, would not lead to more harm than if it were treated with anticoagulation therapy, independent of symptoms.Educational aimsTo understand the term “overdiagnosis” based on its narrow definition and be able to apply it to PE.To outline the diagnostic approach to PE.To summarise what is known about the treatment of incidentally detected PE.To summarise what is known about the treatment of subsegmental PE.To understand in which situations anticoagulation therapy for PE may not be beneficial.

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Section: Overtesting For Pementioning

confidence: 99%

Overdiagnosis of pulmonary embolism: definition, causes and implications

Dobler

2019

Breathe

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“…For studies of investigations (Table ), rates of overuse (and number of corresponding studies in parentheses) comprised: 64% of coagulation tests in patients with various clinical presentations ( n = 1) 22% of thrombophilia screening tests in patients with venous thromboembolism ( n = 1) 34–62% of computed tomography scans of pulmonary arteries in suspected pulmonary thromboembolism ( n = 4) 36–40% of imaging tests in patients with low back pain ( n = 2) 54% of imaging tests in patients with abdominal pain ( n = 1) 63% of blood cultures in patients with suspected sepsis ( n = 1) 23–43% of troponin assays in patients with chest pain ( n = 2) 20% of echocardiographs in patients with various cardiac conditions ( n = 1) 17% of myocardial perfusion scans in patients with stable angina ( n = 1) 38% of referrals for telemetry monitoring in patients at risk of arrythmia 10% of liver biopsies in patients with various types of liver disease ( n = 1) …”

Section: Studies Of Inappropriate Use Of Investigationsmentioning

confidence: 99%

Audit‐based measures of overuse of medical care in Australian hospital practice

Scott

2019

Internal Medicine Journal

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Overuse of care that does not confer benefit to patients and wastes limited resources is being increasingly recognised as a major healthcare problem. The preferred measure of overuse of a specific intervention is applying an evidence‐ or consensus‐based measure of inappropriateness directly to the medical records of individual patients who have received the intervention. This study aimed to assess the extent of overuse of care in hospital practice in Australia based on peer‐reviewed literature that reported clinical audits using explicit measures of overuse applied to patient‐level clinical data. Thirty‐five studies met selection criteria, 14 relating to investigations, 21 to management strategies. Overuse rates above 30% were reported for coagulation tests, blood cultures, troponin assays, abdominal imaging studies, use of telemetry, blood product infusions, polypharmacy in older patients, prescriptions for various medications (gastric acid suppressants, direct oral anticoagulants, inhaled corticosteroids), admissions for low‐risk chest pain and futile interventions in end of life care. Hospital physicians may need to audit their current high‐volume practices and ensure they align with current criteria of appropriateness.

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“…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. However, multiple prior studies have raised a concern about overutilisation of CTPA and non-adherence to the use of clinical probability scores 3 4. The trends towards the use of CTPA is on the rise, with usage greater than 10 times over the last decade 5…”

Section: Introductionmentioning

confidence: 99%

“…The positive yield of CTPA has varied extensively with most studies showing a yield of between 6%6 and 34% 3 7. However, a more recent study found a CTPA positive yield of <1% (0.2%) in a tertiary care centre in the USA.…”

Section: Introductionmentioning

confidence: 99%

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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Underuse of risk assessment and overuse of computed tomography pulmonary angiography in patients with suspected pulmonary thromboembolism

Abstract: More than 50% of patients with suspected PTE may be subject to unwarranted use of CTPA in the absence of pre-test clinical prediction rules coupled with D-dimer assays.

Cited by 30 publications

References 37 publications

Overdiagnosis of pulmonary embolism: definition, causes and implications

Overdiagnosis of pulmonary embolism: definition, causes and implications

Audit‐based measures of overuse of medical care in Australian hospital practice

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

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