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Physician choices in pulmonary embolism testing.

Sahar Zarabi1, Teresa M Chan1, Mathew Mercuri1

  • 1Faculty of Medicine (Zarabi, Varner) and Dalla Lana School of Public Health (Mercuri), University of Toronto, Toronto, Ont.; Faculty of Health Sciences (Chan, Mercuri, Kearon, de Wit), McMaster University, Hamilton, Ont.; Faculty of Medicine (Turcotte, Eagles), University of Ottawa, Ottawa, Ont.; Faculty of Medicine (Grusko), University of Manitoba, Winnipeg, Man.; Faculty of Medicine (Barbic), University of British Columbia, Vancouver, BC; Faculty of Medicine (Bridges), McGill University, Montréal, Que.; Chapel Hill School of Medicine (Houston), University of North Carolina, Chapel Hill, NC.

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Summary

Emergency physicians often deviate from evidence-based pulmonary embolism (PE) testing guidelines. A qualitative study identified 8 domains influencing their choices, highlighting barriers to adopting optimal diagnostic strategies for PE.

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Area of Science:

  • Emergency Medicine
  • Diagnostic Imaging
  • Clinical Decision-Making

Background:

  • Evidence-based guidelines recommend d-dimer testing to exclude pulmonary embolism (PE) in low-probability patients.
  • Emergency physicians often order computed tomography (CT) pulmonary angiography without d-dimer or despite negative results, increasing patient risk.
  • Physician test choices for PE diagnosis require a clearer understanding.

Purpose of the Study:

  • To develop a conceptual framework explaining emergency physicians' diagnostic test choices for suspected pulmonary embolism (PE).
  • To identify factors influencing the adoption or non-adoption of evidence-based PE testing protocols.

Main Methods:

  • A qualitative study involving in-depth interviews with 63 emergency physicians across 9 Canadian hospitals.
  • Physicians discussed their approaches to simulated PE cases and barriers to evidence-based testing.

Main Results:

  • Eight key domains influencing PE testing decisions were identified: physician anxiety, barriers to evidence use (time, knowledge, patient factors), divergent views on testing, Wells score limitations, drive for CT, gestalt estimation, cognitive biases, and inappropriate use of evidence-based testing.
  • Testing choices were influenced by disease characteristics, clinical environment, test attributes, physician factors, and PE probability.

Conclusions:

  • A conceptual framework was developed to explain emergency physicians' test choices for suspected PE.
  • Addressing the identified 8 domains is crucial for implementing effective, evidence-based PE investigation protocols.