Impact of a Clinical Decision Support System on CT Pulmonary Angiography Yield and Utilization in Hospitalized...

The aims of this study were to determine whether point-of-order clinical decision support (CDS) based on the Wells criteria improves CT pulmonary angiography (CTPA) yield and utilization in hospitalized patients in an enterprise-wide health system and to identify yield-related factors.

This retrospective, institutional review board-approved, cross-sectional study in an urban, multi-institution health system included hospitalized patients undergoing CTPA 12 months before and after CDS implementation (entire cohort). The χ² test was used to compare pulmonary embolism (PE) yield in patients in whom providers overrode versus followed CDS alerts after CDS implementation. It was also used to compare utilization and yield before- versus after the intervention. Univariate and multivariable regression analyses were performed on patient factors and post-CDS Wells scores to evaluate yield-related factors.

For 2,429 inpatient CT pulmonary angiographic examinations after the intervention, CTPA yield was significantly higher when CDS recommendations were followed (18.3% [250 of 1,365]) compared with those overridden (14.2% [151 of 1,064]) (P < .01). For 5,372 CT pulmonary angiographic examinations in the entire cohort, there was no difference in PE yield before (448 of 2,943 [15.2%]) versus after (401 of 2,429 [16.5%]) CDS implementation (P = .20). However, in 340,146 admissions over the study period, a 7.4% relative decrease in CTPA utilization (from 17.5 to 16.2 CT pulmonary angiographic examinations per 1,000 admissions before and after CDS, respectively, P = .003) was observed.

When CDS recommendations were followed, the yield of CTPA was significantly higher than when clinicians overrode CDS alerts. In addition, point-of-order CDS to reduce unnecessary CTPA in hospitalized patients resulted in a significant decrease in CTPA utilization after CDS implementation, with a modest although nonsignificant increase in CTPA yield.