Retrospective Analysis of the Computed Tomography Pulmonary Angiogram Utilization Patterns in the Emergency
Craig Ferguson1, Gavin Low1, Christopher Fung1
1Department of Radiology and Diagnostic Imaging, University of Alberta, University of Alberta Hospital, Edmonton, Alberta, Canada.
Insights
Clinical decision-making (CDM) tools are recommended for pulmonary embolism diagnosis, but this study found a high failure rate in their use. Using CDM tools resulted in a higher positive pulmonary embolism rate compared to clinical gestalt.
Area of Science:
- Emergency Medicine
- Radiology
- Diagnostic Accuracy
Background:
- Clinical decision-making (CDM) tools are recommended over clinical gestalt for pulmonary embolism (PE) evaluation.
- Computed tomography pulmonary angiogram (CTPA) is a key diagnostic tool for PE.
Purpose of the Study:
- To investigate CTPA utilization patterns.
- To identify factors contributing to the inappropriate use of diagnostic tools for PE.
Main Methods:
- Retrospective cohort study of CTPA studies ordered by emergency physicians.
- Collected data for Wells' score, revised Geneva score, and PERC criteria.
- Analyzed data using chi-square, Fisher's exact, and independent-samples t tests.
Main Results:
- 26.7% of CTPA studies did not appropriately follow a CDM tool.
- Failure rates varied between community (14.9%) and tertiary hospitals (24.6%-27.9%).
- CDM tool use yielded a 15.0% positive PE rate versus 5.9% for gestalt (P=.026).
Conclusions:
- High rates of failure to appropriately use CDM tools were observed.
- CDM tools demonstrated a higher positive CTPA rate compared to clinical gestalt.
Objectives:
Guidelines and high-quality studies recommend using clinical decision-making (CDM) tools over clinical gestalt when evaluating a patient for pulmonary embolism. The purpose of this study is to investigate our computed tomography pulmonary angiogram (CTPA) utilization patterns and identify causal factors.
Methods:
A retrospective cohort study of CTPA studies ordered by emergency physicians in January, April, July, and October 2017 was undertaken. All necessary information to categorize patients by Wells' score, revised Geneva score, and pulmonary embolism rule-out criteria (PERC) was collected. In addition, various bloodwork, chest radiograph, and computed tomography results were collected. This data was analysed by the Pearson chi-square test or Fisher's exact test for categorical data and independent-samples t test for continuous variables.
Results:
A total of 510 CTPA studies were performed, with a mean age was 61.6 and a 50.6% female population. 136 studies (26.7%) failed to appropriately follow any CDM tool. CDM tool failure rate was dependent on whether the study was ordered from a community (14.9%) or tertiary hospital (University of Alberta Hospital, 27.9% and Royal Alexandra Hospital, 24.6%) (P = .038). Of these 136 studies, 31 were low/moderate risk and the d-dimer was negative. The remainder were either PERC-negative or low/moderate risk without d-dimer performed. The cumulative positive pulmonary embolism rate was 12.5%. With utilization of a CDM tool, the positive pulmonary embolism rate was 15.0%, compared to 5.9% when using gestalt (P = .026).
Conclusions:
This study confirms a high rate of CDM tool use failure, and a higher positive CTPA rate for CDM tools compared to clinical gestalt.
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