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

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Abstract

Purpose

To describe the inter-physician variability in the utilisation rate and diagnostic yield of computed tomography pulmonary angiography (CTPA) among a group of emergency department (ED) physicians working in a similar clinical environment.

Methods

We collected data on all CTPA studies ordered by ED physicians at three affiliated sites during a 2-year period between January 1, 2016, and December 31, 2017. For each physician, we calculated individual CTPA utilisation rate (total number of CTPAs ordered per 1000 ED visits) and diagnostic yield (percentage of CTPAs that were positive for PE). Additional analysis was carried out in order to identify the highest orderers of CTPA and their diagnostic yield.

Results

Seventy-seven ED physicians who collectively ordered a total of 2788 CTPAs were included in the study. Utilisation rates ranged from 1.1 to 22.2 CTPA per 1000 ED visits (median: 5.2 CTPA/1000 ED visits; 25%ile: 3.6 CTPA/1000 ED visits; 75%ile: 7.9 CTPA/1000 ED visits) and the CTPA diagnostic yields ranged from 0% to 33% (median: 9.1%; 25%ile: 5.2%; 75%ile: 16.1%). Those physicians in the lower quartile for ordering rate had a higher mean diagnostic yield when compared to the higher quartiles.

Conclusion

The findings of this study demonstrate variability in CTPA ordering patterns and diagnostic yields among physicians working within the same clinical environment. There is some suggestion that those physicians who order disproportionately higher numbers of CTPAs have lower diagnostic yields.

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References

  1. Venkatesh AK, Agha L, Abaluck J, Rothenberg C, Kabrhel C, Raja AS (2018) Trends and variation in the utilization and diagnostic yield of chest imaging for Medicare patients with suspected pulmonary embolism in the emergency department. AJR Am J Roentgenol 210(3):572–577

    Article  Google Scholar 

  2. Weir ID, Drescher F, Cousin D, Fraser ET, Lee R, Berman L, Strauss E, Wang Y, Fine JM (2010) Trends in use and yield of chest computed tomography with angiography for diagnosis of pulmonary embolism in a Connecticut hospital emergency department. Conn Med 74(1):5–9

    PubMed  Google Scholar 

  3. Wiener RS, Schwartz LM, Woloshin S (2011) Time trends in pulmonary embolism in the United States: evidence of overdiagnosis. Arch Intern Med 171(9):831–837

    Article  Google Scholar 

  4. Einstein AJ, Henzlova MJ, Rajagopalan S (2007) Estimating risk of cancer associated with radiation exposure from 64-slice computed tomography coronary angiography. JAMA 298(3):317–323

    Article  CAS  Google Scholar 

  5. Smith-Bindman R, Miglioretti DL, Johnson E, Lee C, Feigelson HS, Flynn M, Greenlee RT, Kruger RL, Hornbrook MC, Roblin D, Solberg LI, Vanneman N, Weinmann S, Williams AE (2012) Use of diagnostic imaging studies and associated radiation exposure for patients enrolled in large integrated health care systems, 1996-2010. Jama 307(22):2400–2409

    Article  CAS  Google Scholar 

  6. Hutchinson BD, Navin P, Marom EM, Truong MT, Bruzzi JF (2015) Overdiagnosis of pulmonary embolism by pulmonary CT angiography. AJR Am J Roentgenol 205(2):271–277

    Article  Google Scholar 

  7. Anjum O, Bleeker H, Ohle R (2019) Computed tomography for suspected pulmonary embolism results in a large number of non-significant incidental findings and follow-up investigations. Emerg Radiol 26(1):29–35

    Article  Google Scholar 

  8. Singh B, Mommer SK, Erwin PJ, Mascarenhas SS, Parsaik AK (2013) Pulmonary embolism rule-out criteria (PERC) in pulmonary embolism--revisited: a systematic review and meta-analysis. Emerg Med J 30(9):701–706

    Article  Google Scholar 

  9. Stojanovska J, Carlos RC, Kocher KE, Nagaraju A, Guy K, Kelly AM, Chughtai AR, Kazerooni EA (2015) CT pulmonary angiography: using decision rules in the emergency department. J Am Coll Radiol 12(10):1023–1029

    Article  Google Scholar 

  10. Drescher FS, Chandrika S, Weir ID, Weintraub JT, Berman L, Lee R, Van Buskirk PD, Wang Y, Adewunmi A, Fine JM (2011) Effectiveness and acceptability of a computerized decision support system using modified Wells criteria for evaluation of suspected pulmonary embolism. Ann Emerg Med 57(6):613–621

    Article  Google Scholar 

  11. van Belle A, Buller HR, Huisman MV, Huisman PM, Kaasjager K, Kamphuisen PW, Kramer MH, Kruip MJ, Kwakkel-van Erp JM, Leebeek FW et al (2006) Effectiveness of managing suspected pulmonary embolism using an algorithm combining clinical probability, D-dimer testing, and computed tomography. Jama 295(2):172–179

    Article  Google Scholar 

  12. Walen S, de Boer E, Edens MA, van der Worp CAJ, Boomsma MF, van den Berg JWK (2016) Mandatory adherence to diagnostic protocol increases the yield of CTPA for pulmonary embolism. Insights Imaging 7(5):727–734

    Article  Google Scholar 

  13. Agarwal A, Persaud J, Grabinski R, Rabinowitz D, Bremner A, Mendelson R (2012) Pulmonary embolism: are we there yet? J Med Imaging Radiat Oncol 56(3):270–281

    Article  Google Scholar 

  14. Gupta A, Raja AS, Khorasani R (2014) Examining clinical decision support integrity: is clinician self-reported data entry accurate? J Am Med Inform Assoc 21(1):23–26

    Article  Google Scholar 

  15. Ong CW, Malipatil V, Lavercombe M, Teo KGW, Coughlin PB, Leach D, Spanger MC, Thien F (2013) Implementation of a clinical prediction tool for pulmonary embolism diagnosis in a tertiary teaching hospital reduces the number of computed tomography pulmonary angiograms performed. Intern Med J 43(2):169–174

    Article  CAS  Google Scholar 

  16. Kline JA, Courtney DM, Beam DM, King MC, Steuerwald M (2009) Incidence and predictors of repeated computed tomographic pulmonary angiography in emergency department patients. Ann Emerg Med 54(1):41–48

    Article  Google Scholar 

  17. Corwin MT, Donohoo JH, Partridge R, Egglin TK, Mayo-Smith WW (2009) Do emergency physicians use serum D-dimer effectively to determine the need for CT when evaluating patients for pulmonary embolism? Review of 5,344 consecutive patients. AJR Am J Roentgenol 192(5):1319–1323

    Article  Google Scholar 

  18. Yin F, Wilson T, Della Fave A, Larsen M, Yoon J, Nugusie B, Freeland H, Chow RD (2012) Inappropriate use of D-dimer assay and pulmonary CT angiography in the evaluation of suspected acute pulmonary embolism. Am J Med Qual 27(1):74–79

    Article  Google Scholar 

  19. Chen Z, Deblois S, Toporowicz K, Boldeanu I, Francoeur M-O, Sadouni M, Lepanto L, Chartrand-Lefebvre C (2019) Yield of CT pulmonary angiography in the diagnosis of acute pulmonary embolism: short report. BMC Res Notes 12(1):41–41

    Article  Google Scholar 

  20. Costa AF, Basseri H, Sheikh A, Stiell I, Dennie C (2014) The yield of CT pulmonary angiograms to exclude acute pulmonary embolism. Emerg Radiol 21(2):133–141

    Article  Google Scholar 

  21. Chen YA, Gray BG, Bandiera G, MacKinnon D, Deva DP (2015) Variation in the utilization and positivity rates of CT pulmonary angiography among emergency physicians at a tertiary academic emergency department. Emerg Radiol 22(3):221–229

    Article  Google Scholar 

  22. Groth M, Henes FO, Mayer U, Regier M, Adam G, Begemann PGC (2012) Age-related incidence of pulmonary embolism and additional pathologic findings detected by computed tomography pulmonary angiography. Eur J Radiol 81(8):1913–1916

    Article  CAS  Google Scholar 

  23. Perrier A, Roy PM, Sanchez O, Le Gal G, Meyer G, Gourdier AL, Furber A, Revel MP, Howarth N, Davido A et al (2005) Multidetector-row computed tomography in suspected pulmonary embolism. N Engl J Med 352(17):1760–1768

    Article  CAS  Google Scholar 

  24. Booker MT, Johnson JO (2017) Optimizing CT pulmonary angiogram utilization in a community emergency department: a pre- and postintervention study. J Am Coll Radiol 14(1):65–71

    Article  Google Scholar 

  25. Raja AS, Ip IK, Dunne RM, Schuur JD, Mills AM, Khorasani R (2015) Effects of performance feedback reports on adherence to evidence-based guidelines in use of CT for evaluation of pulmonary embolism in the emergency department: a randomized trial. AJR Am J Roentgenol 205(5):936–940

    Article  Google Scholar 

  26. Chong J, Lee TC, Attarian A, Sivakumaran L, Troquet J-M, McDonald EG, Gallix B (2018) Association of lower diagnostic yield with high users of CT pulmonary angiogram. JAMA Intern Med 178(3):412–413

    Article  Google Scholar 

  27. Abaluck J, Agha L, Kabrhel C, Raja A, Venkatesh A (2016) The determinants of productivity in medical testing: intensity and allocation of care. Am Econ Rev 106(12):3730–3764

    Article  Google Scholar 

  28. Buchanan I, Teeples T, Carlson M, Steenblik J, Bledsoe J, Madsen T (2017) Pulmonary embolism testing among emergency department patients who are pulmonary embolism rule-out criteria negative. Acad Emerg Med Off J Soc Acad Emerg Med 24(11):1369–1376

    Article  Google Scholar 

  29. Burge AJ, Freeman KD, Klapper PJ, Haramati LB (2008) Increased diagnosis of pulmonary embolism without a corresponding decline in mortality during the CT era. Clin Radiol 63(4):381–386

    Article  CAS  Google Scholar 

  30. Kindermann DR, McCarthy ML, Ding R, Frohna WJ, Hansen J, Maloy K, Milzman DP, Pines JM (2014) Emergency department variation in utilization and diagnostic yield of advanced radiography in diagnosis of pulmonary embolus. J Emerg Med 46(6):791–799

    Article  Google Scholar 

  31. Richardson S, Lucas E, Cohen S, Zhang M, Qiu G, Khan S, McGinn T (2019) Predictors of overtesting in pulmonary embolism diagnosis. Acad Radiol

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Acknowledgements

The authors would like to thank Dr. Oscar Karbi, Mr. Ishmail Sheri, Mr. Daniel Levay, Mr. Shaun Ghanny, Ms. Desa Marin, Ms. Priscilla Matthews and the Brampton Civic Hospital Emergency Department Governance Committee for their contributions to this manuscript. The authors acknowledge support from the CanVECTOR Network; the Network receives grant funding from the Canadian Institutes of Health Research (Funding Reference: CDT-142654).

Funding

No external funding was secured for this study. Institutional support was provided by William Osler Health System, the Brampton Civic Hospital Emergency Department Governance Committee, McMaster University Department of Medicine and University of Toronto Department of Family and Community Medicine.

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Authors and Affiliations

  1. Department of Family Medicine, McMaster University, Hamilton, ON, Canada

    Leila Salehi & Prashant Phalpher

  2. Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada

    Leila Salehi & Christopher Meaney

  3. William Osler Health System, Rm. S1.184, 2100 Bovaird Drive East, Brampton, Ontario, L6R 3J7, Canada

    Leila Salehi, Prashant Phalpher, Marc Ossip & Rahim Valani

  4. Division of Emergency Medicine, Department of Medicine, McMaster University, Hamilton, ON, Canada

    Rahim Valani & Mathew Mercuri

Authors
  1. Leila Salehi
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  2. Prashant Phalpher
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Correspondence to Leila Salehi.

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Appendix

Appendix

Fig. 2
figure 2

Total number of ED visits and total number of CTPAs ordered by each of the 77 ED physicians, 2016–2017

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Fig. 3
figure 3

Frequency distribution of total ED visits per physician among the 77 ED physicians, 2016–2017

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Fig. 4
figure 4

Frequency distribution of total number of CTPAs ordered by each physician, 2016–2017

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Salehi, L., Phalpher, P., Ossip, M. et al. Variability in practice patterns among emergency physicians in the evaluation of patients with a suspected diagnosis of pulmonary embolism.. Emerg Radiol 27, 127–134 (2020). https://doi.org/10.1007/s10140-019-01740-w

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  • DOI: https://doi.org/10.1007/s10140-019-01740-w

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