Variability in practice patterns among emergency physicians in the evaluation of patients with a suspected diagnosis of pulmonary embolism.

Salehi, Leila; Phalpher, Prashant; Ossip, Marc; Meaney, Christopher; Valani, Rahim; Mercuri, Mathew

doi:10.1007/s10140-019-01740-w

Cited by 9 publications

(12 citation statements)

References 30 publications

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“…These considerations should always be taken into account, especially when ordering a CTPA for a patient at low risk of PE. Other diagnostic tools are recommended to rule out PE before progressing to CTPA for a definitive diagnosis; these include clinical decision rules based on X-ray findings, patient risk factors, such as Wells scores and pulmonary embolism rule-out criteria, and D-dimer testing [1,5]. Recent literature indicates that D-dimer testing was used in less than half of patients with CTPA and the yield rate for PE was higher in centers with higher D-dimer usage [6].…”

Section: Introductionmentioning

confidence: 99%

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Computed Tomography Angiography for Detection of Pulmonary Embolism in Western Australia Shows Increasing Use with Decreasing Diagnostic Yield

Youens

Doust

et al. 2023

JCM

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(1) Background: Pulmonary embolism (PE) can be fatal. Computed tomography pulmonary angiography (CTPA) can accurately diagnose PE, but it should be used only when reasonable pre-test probability exists. Overtesting with CTPA exposes patients to excess ionizing radiation and contrast media, while PE overdiagnosis leads to the treatment of small emboli unlikely to cause harm. This study assessed trends in CTPA use and diagnostic yield. We also assessed trends in PE hospitalizations and mortality to indicate PE severity. (2) Methods: Analysis of Western Australian linked administrative data for 2003–2015 including hospitalizations, emergency department (ED) attendances, and CTPA performed at hospitals. Age-sex standardized trends were calculated for CTPA use, PE hospitalizations, and mortality (as a proxy for severity). Logistic regression assessed diagnostic yield of CTPA following unplanned ED presentations. (3) Results: CTPA use increased from 3.3 per 10,000 person-years in 2003 (95% CI 3.0–3.6) to 17.1 per 10,000 person-years (16.5–17.7) in 2015. Diagnostic yield of CTPA increased from 12.7% in 2003 to 17.4% in 2005, declining to 12.2% in 2015 (p = 0.049). PE hospitalizations increased from 3.8 per 10,000 (3.5–4.1) in 2003 to 5.2 per 10,000 (4.8–5.5) in 2015. Mortality remained constant at 0.50 per 10,000 (0.39–0.62) in 2003 and 0.42 per 10,000 (0.32–0.51) in 2015. (4) Conclusions: CTPA increased from 2003 to 2015, while diagnostic yield decreased, potentially indicating overtesting. PE mortality remained constant despite increasing hospitalizations, likely indicating a higher proportion of less severe cases. As treatment can be harmful, this could represent overdiagnosis.

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Section: Introductionmentioning

confidence: 99%

“…Furthermore, PE treatments carry significant risks. Treatment involves anticoagulation [12], which increases bleeding risk [5]. If CT scanning results in the detection of small, non-clinically significant PEs, the balance of benefit and harm resulting from anticoagulation becomes less favorable.…”

Section: Introductionmentioning

confidence: 99%

Computed Tomography Angiography for Detection of Pulmonary Embolism in Western Australia Shows Increasing Use with Decreasing Diagnostic Yield

Youens

Doust

et al. 2023

JCM

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“…Given the same CT likelihood ratio for a positive test, the posttest probability would decrease, giving a lower diagnostic yield and vice versa . In addition, inadequate risk stratification and lack of adherence to imaging guidelines could be contributing factors in this relationship; however, the appropriateness of CT scans cannot be judged in the absence of follow-up outcome data [23].…”

Section: Discussionmentioning

confidence: 99%

Computed tomography brain scan utilization in patients with headache presenting to emergency departments: a multinational study

Chu,

Kelly,

Keijzers

et al. 2023

European Journal of Emergency Medicine

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Background and importance Recommended indications for emergency computed tomography (CT) brain scans are not only complex and evolving, but it is also unknown whether they are being followed in emergency departments (EDs).Objective To determine the CT utilization and diagnostic yield in the ED in patients with headaches across broad geographical regions.Design Secondary analysis of data from a multinational cross-sectional study of ED headache presentations over one month in 2019.Setting and participants Hospitals from 10 participating countries were divided into five geographical regions [Australia and New Zealand (ANZ); Colombia; Europe: Belgium, France, UK, and Romania; Hong Kong and Singapore (HKS); and Turkey). Adult patients with nontraumatic headache as the primary presenting complaint were included. Patients were identified from ED management systems. Outcome measures and analysisThe outcome measures were CT utilization and diagnostic yield. CT utilization was calculated using a multilevel binary logistic regression model to account for clustering of patients within hospitals and regions. Imaging data (CT requests and reports) were sourced from radiology management systems. Main resultsThe study included 5281 participants. Median (interquartile range) age was 40 (29-55) years, 66% were women. Overall mean CT utilization was 38.5% [95% confidence interval (CI), 30.4-47.4%]. Regional utilization was highest in Europe (46.0%) and lowest in Turkey (28.9%), with HKS (38.0%), ANZ (40.0%), and Colombia (40.8%) in between. Its distribution across hospitals was approximately symmetrical. There was greater variation in CT utilization between hospitals within a region than between regions (hospital variance 0.422, region variance 0.100). Overall mean CT diagnostic yield was 9.9% (95% CI, 8.7-11.3%).Its distribution across hospitals was positively skewed. Regional yield was lower in Europe (5.4%) than in other regions: Colombia (9.1%), HKS (9.7%), Turkey (10.6%), and ANZ (11.2%). There was a weak negative correlation between utilization and diagnostic yield (r = −0.248). ConclusionIn this international study, there was a high variation (28.9-46.6%) in CT utilization and diagnostic yield (5.4-11.2%) across broad geographic regions. Europe had the highest utilization and the lowest yield. The study findings provide a foundation to address variation in neuroimaging in ED headache presentations. European

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“…This data was collected through our institution's Radiology Information Systems (RIS), our Electronic Medical Records system and the National Ambulatory Care Reporting System (NACRS). The methodology for data collection has been published elsewhere [27]. The collected variables were: age, sex, chief complaint, Canadian Triage and Acuity Scale (CTAS) level, any serum D-Dimer assay values obtained in the 24 h prior to undergoing the CTPA, and the radiologists' report of the CTPA findings.…”

Section: Data Collectionmentioning

confidence: 99%

Utilization of serum D-dimer assays prior to computed tomography pulmonary angiography scans in the diagnosis of pulmonary embolism among emergency department physicians: a retrospective observational study

Salehi

Phalpher

et al. 2021

BMC Emerg Med

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Background A variety of evidence-based algorithms and decision rules using D-Dimer testing have been proposed as instruments to allow physicians to safely rule out a pulmonary embolism (PE) in low-risk patients. Objective To describe the prevalence of D-Dimer utilization among emergency department (ED) physicians and its impact on positive yields and utilization rates of Computed Tomography Pulmonary Angiography (CTPA). Methods Data was collected on all CTPA studies ordered by ED physicians at three sites during a 2-year period. Using a chi-square test, we compared the diagnostic yield for those patients who had a D-Dimer prior to their CTPA and those who did not. Secondary analysis was done to examine the impact of D-Dimer testing prior to CTPA on individual physician diagnostic yield or utilization rate. Results A total of 2811 CTPAs were included in the analysis. Of these, 964 CTPAs (34.3%) were ordered without a D-Dimer, and 343 (18.7%) underwent a CTPA despite a negative D-Dimer. Those CTPAs preceded by a D-Dimer showed no significant difference in positive yields when compared to those ordered without a D-Dimer (9.9% versus 11.3%, p = 0.26). At the individual physician level, no statistically significant relationship was found between D-Dimer utilization and CTPA utilization rate or diagnostic yield. Conclusion This study provides evidence of suboptimal adherence to guidelines in terms of D-Dimer screening prior to CTPA, and forgoing CTPAs in patients with negative D-Dimers. However, the lack of a positive impact of D-Dimer testing on either CTPA diagnostic yield or utilization rate is indicative of issues relating to the high false-positive rates associated with D-Dimer screening.

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Variability in practice patterns among emergency physicians in the evaluation of patients with a suspected diagnosis of pulmonary embolism.

Cited by 9 publications

References 30 publications

Computed Tomography Angiography for Detection of Pulmonary Embolism in Western Australia Shows Increasing Use with Decreasing Diagnostic Yield

Computed Tomography Angiography for Detection of Pulmonary Embolism in Western Australia Shows Increasing Use with Decreasing Diagnostic Yield

Computed tomography brain scan utilization in patients with headache presenting to emergency departments: a multinational study

Utilization of serum D-dimer assays prior to computed tomography pulmonary angiography scans in the diagnosis of pulmonary embolism among emergency department physicians: a retrospective observational study

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