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Mandatory Assignment of Modified Wells Score Before CT Angiography for Pulmonary Embolism Fails to Improve
Glenn K Geeting1, Michael Beck2, Michael A Bruno3
11 Department of Emergency Medicine, The Pennsylvania State University College of Medicine, Hershey, PA.
Insights
Implementing a mandatory pretest probability rule in computerized physician order-entry systems improved the appropriate use of CT angiography for diagnosing pulmonary embolism. While appropriate ordering increased, overall utilization and positive results remained unchanged.
Area of Science:
- Emergency Medicine
- Radiology
- Health Informatics
Background:
- Pulmonary embolism (PE) diagnosis relies heavily on imaging, with CT angiography (CTA) of pulmonary arteries being a key tool.
- Appropriate utilization of CTA is crucial to balance diagnostic accuracy with resource efficiency and patient safety.
- Computerized physician order-entry (CPOE) systems offer opportunities for clinical decision support to optimize imaging orders.
Purpose of the Study:
- To evaluate the impact of integrating a mandatory pretest probability rule into the CPOE process on the appropriateness of pulmonary CTA orders for PE diagnosis in the emergency department (ED).
Main Methods:
- A retrospective analysis of electronic medical records for 96,507 adult ED visits over two years was conducted.
- The primary outcome measured was the appropriateness of pulmonary CTA use.
- Logistic regression analysis was employed to assess changes in appropriate use, overuse, and underuse post-intervention, controlling for patient characteristics.
Main Results:
- Pulmonary CTA was appropriately used in 67.2% of cases meeting specific pretest probability criteria (modified Wells score ≥ 4, positive d-dimer, or both).
- Overuse and underuse rates were 19.3% and 13.5%, respectively.
- Each month post-intervention, the odds of appropriate CTA use increased by 4% (OR = 1.04), and the odds of overuse decreased (OR = 0.93), without significant changes in overall CTA utilization or positivity rates.
Conclusions:
- Mandatory pretest probability assessment within CPOE significantly improved the appropriate ordering of pulmonary CTA for PE diagnosis.
- The intervention did not alter the rate of positive PE diagnoses or overall CTA utilization.
- Physicians may have adapted by inflating pretest probability scores, suggesting a need for further refinement of decision support tools.
Objective:
The objective of our study was to determine the impact of embedding a pretest probability rule that is required during the computerized physician order-entry (CPOE) process on the appropriateness of CT angiography (CTA) of the pulmonary arteries for the diagnosis of pulmonary embolism (PE) in the emergency department (ED).
Materials And Methods:
Data were obtained from the electronic medical records of all adults who visited the ED from October 17, 2010, through October 17, 2012 (n = 96,507). The primary outcome was the appropriateness of pulmonary CTA. Logistic regression was used to test whether rates of appropriate use, overuse, and underuse of pulmonary CTA improved significantly after the implementation of the decision support tool when controlling for other patient characteristics.
Results:
Pulmonary CTA was appropriately used in 67.2% of patients with a modified Wells score of ≥ 4, a positive d-dimer test result, or both. CTA was overused in 19.3% of patients and underused in 13.5% of patients. Each additional month after the start of the intervention was associated with a 4-percentage point increase in the odds that the modified Wells score would indicate CTA had been used appropriately (odds ratio [OR] = 1.04; 95% CI, 1.01-1.07) and significantly lowered the odds of overuse of CTA (OR = 0.93; 95% CI, 0.90-0.96) based on the modified Wells score. These changes were not associated with any significant alteration in the level of CTA utilization or the positivity rate.
Conclusion:
The addition of a mandatory field in the CPOE record was associated with a significant improvement in the appropriate ordering of pulmonary CTA but did not change the PE positive rate or CTA utilization. It seems likely that physicians gradually inflated the modified Wells scores in spite of the fact that a threshold modified Wells score was not required to perform pulmonary CTA.
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