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Chu K, Kelly AM, Keijzers G, Kinnear F, Kuan WS, Graham C, Laribi S, Roberts T, Karamercan M, Cardozo-Ocampo A, Kamona S, Body R, Horner D, Klim S, Brown N, Wijeratne T. Computed tomography brain scan utilization in patients with headache presenting to emergency departments: a multinational study. Eur J Emerg Med 2023; 30:356-364. [PMID: 37310953 DOI: 10.1097/mej.0000000000001055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
BACKGROUND AND IMPORTANCE Recommended indications for emergency computed tomography (CT) brain scans are not only complex and evolving, but it is also unknown whether they are being followed in emergency departments (EDs). OBJECTIVE To determine the CT utilization and diagnostic yield in the ED in patients with headaches across broad geographical regions. DESIGN Secondary analysis of data from a multinational cross-sectional study of ED headache presentations over one month in 2019. SETTING AND PARTICIPANTS Hospitals from 10 participating countries were divided into five geographical regions [Australia and New Zealand (ANZ); Colombia; Europe: Belgium, France, UK, and Romania; Hong Kong and Singapore (HKS); and Turkey). Adult patients with nontraumatic headache as the primary presenting complaint were included. Patients were identified from ED management systems. OUTCOME MEASURES AND ANALYSIS The outcome measures were CT utilization and diagnostic yield. CT utilization was calculated using a multilevel binary logistic regression model to account for clustering of patients within hospitals and regions. Imaging data (CT requests and reports) were sourced from radiology management systems. MAIN RESULTS The study included 5281 participants. Median (interquartile range) age was 40 (29-55) years, 66% were women. Overall mean CT utilization was 38.5% [95% confidence interval (CI), 30.4-47.4%]. Regional utilization was highest in Europe (46.0%) and lowest in Turkey (28.9%), with HKS (38.0%), ANZ (40.0%), and Colombia (40.8%) in between. Its distribution across hospitals was approximately symmetrical. There was greater variation in CT utilization between hospitals within a region than between regions (hospital variance 0.422, region variance 0.100). Overall mean CT diagnostic yield was 9.9% (95% CI, 8.7-11.3%). Its distribution across hospitals was positively skewed. Regional yield was lower in Europe (5.4%) than in other regions: Colombia (9.1%), HKS (9.7%), Turkey (10.6%), and ANZ (11.2%). There was a weak negative correlation between utilization and diagnostic yield ( r = -0.248). CONCLUSION In this international study, there was a high variation (28.9-46.6%) in CT utilization and diagnostic yield (5.4-11.2%) across broad geographic regions. Europe had the highest utilization and the lowest yield. The study findings provide a foundation to address variation in neuroimaging in ED headache presentations.
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Affiliation(s)
- Kevin Chu
- Emergency and Trauma Centre, Royal Brisbane and Women's Hospital, Brisbane
- Faculty of Medicine, University of Queensland, Queensland
| | - Anne-Maree Kelly
- Joseph Epstein Centre for Emergency Medicine Research, Western Health, Melbourne
- Department of Medicine, Western Health, Melbourne Medical School, University of Melbourne, Melbourne, Victoria
| | - Gerben Keijzers
- Department of Emergency Medicine, Gold Coast University Hospital, Gold Coast
- School of Medicine, Bond University, Gold Coast
- School of Medicine, Griffith University, Gold Coast, Queensland, Australia
| | | | - Win Sen Kuan
- Emergency Medicine Department, National University Hospital, National University Health System, Singapore
| | - Colin Graham
- Accident and Emergency Medicine Academic Unit, Chinese University of Hong Kong, Hong Kong SAR, China
| | - Said Laribi
- Department of Emergency Medicine, Tours University Hospital, Tours, France
| | - Tom Roberts
- Faculty of Health and Life Sciences, University of the West of England, Bristol, UK
| | - Mehmet Karamercan
- Department of Emergency Medicine, Faculty of Medicine, Gazi University, Ankara, Turkey
| | | | - Sinan Kamona
- Adult Emergency Department, Auckland City Hospital
- Faculty of Health and Medical Sciences, University of Auckland, Auckland, New Zealand
| | - Richard Body
- Emergency Department, Manchester Royal Infirmary, Manchester University NHS Foundation Trust
- Division of Cardiovascular Science, University of Manchester, Manchester
| | - Daniel Horner
- Emergency Department, Northern Care Alliance NHS Foundation Trust, Salford
- Division of Infection, Immunity and Respiratory Medicine, University of Manchester, Manchester, UK
| | - Sharon Klim
- Joseph Epstein Centre for Emergency Medicine Research, Western Health, Melbourne
- Department of Medicine, Western Health, Melbourne Medical School, University of Melbourne, Melbourne, Victoria
| | - Nathan Brown
- Emergency and Trauma Centre, Royal Brisbane and Women's Hospital, Brisbane
- Faculty of Medicine, University of Queensland, Queensland
| | - Tissa Wijeratne
- Department of Medicine, Western Health, Melbourne Medical School, University of Melbourne, Melbourne, Victoria, Australia
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Thurlow LE, Van Dam PJ, Prior SJ, Tran V. How Tasmanian Emergency Departments 'Choose Wisely' When Investigating Suspected Pulmonary Embolism. Healthcare (Basel) 2023; 11:healthcare11111599. [PMID: 37297739 DOI: 10.3390/healthcare11111599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Revised: 05/26/2023] [Accepted: 05/28/2023] [Indexed: 06/12/2023] Open
Abstract
Overuse of computed tomography pulmonary angiograms (CTPAs) for diagnosis of pulmonary embolism (PE) has been recognised as an issue for over ten years, with Choosing Wisely Australia recommending that CTPAs only be ordered if indicated by a clinical practice guideline (CPG). This study aimed to explore the use of evidence-based practice within regional Tasmanian emergency departments in relation to CTPA orders by determining whether CTPAs were ordered in accordance with validated CPGs. We conducted a retrospective medical record review of all patients who underwent CTPA across all public emergency departments in Tasmania between 1 August 2018 and 31 December 2019 inclusive. Data from 2758 CTPAs across four emergency departments were included. PE was reported in 343 (12.4%) of CTPAs conducted, with yield ranging from 8.2% to 16.1% between the four sites. Overall, 52.1% of participants had neither a CPG documented, nor a D-dimer conducted before their scan. A CPG was documented before 11.8% of scans, while D-dimer was conducted before 43% of CTPAs. The findings presented in this study indicate that Tasmanian emergency departments are not consistently 'Choosing Wisely' when investigating PE. Further research is required to identify explanations for these findings.
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Affiliation(s)
- Lauren E Thurlow
- Tasmanian School of Medicine, College of Health and Medicine, University of Tasmania, Hobart, TAS 7000, Australia
| | - Pieter J Van Dam
- School of Nursing, College of Health and Medicine, University of Tasmania, Burnie, TAS 7320, Australia
| | - Sarah J Prior
- Tasmanian School of Medicine, College of Health and Medicine, University of Tasmania, Burnie, TAS 7320, Australia
| | - Viet Tran
- Tasmanian School of Medicine, College of Health and Medicine, University of Tasmania, Hobart, TAS 7000, Australia
- Emergency Department, Royal Hobart Hospital, Hobart, TAS 7000, Australia
- Menzies Institute for Medical Research, University of Tasmania, Hobart, TAS 7000, Australia
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Computed Tomography Angiography for Detection of Pulmonary Embolism in Western Australia Shows Increasing Use with Decreasing Diagnostic Yield. J Clin Med 2023; 12:jcm12030980. [PMID: 36769627 PMCID: PMC9917579 DOI: 10.3390/jcm12030980] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 01/23/2023] [Accepted: 01/25/2023] [Indexed: 01/31/2023] Open
Abstract
(1) Background: Pulmonary embolism (PE) can be fatal. Computed tomography pulmonary angiography (CTPA) can accurately diagnose PE, but it should be used only when reasonable pre-test probability exists. Overtesting with CTPA exposes patients to excess ionizing radiation and contrast media, while PE overdiagnosis leads to the treatment of small emboli unlikely to cause harm. This study assessed trends in CTPA use and diagnostic yield. We also assessed trends in PE hospitalizations and mortality to indicate PE severity. (2) Methods: Analysis of Western Australian linked administrative data for 2003-2015 including hospitalizations, emergency department (ED) attendances, and CTPA performed at hospitals. Age-sex standardized trends were calculated for CTPA use, PE hospitalizations, and mortality (as a proxy for severity). Logistic regression assessed diagnostic yield of CTPA following unplanned ED presentations. (3) Results: CTPA use increased from 3.3 per 10,000 person-years in 2003 (95% CI 3.0-3.6) to 17.1 per 10,000 person-years (16.5-17.7) in 2015. Diagnostic yield of CTPA increased from 12.7% in 2003 to 17.4% in 2005, declining to 12.2% in 2015 (p = 0.049). PE hospitalizations increased from 3.8 per 10,000 (3.5-4.1) in 2003 to 5.2 per 10,000 (4.8-5.5) in 2015. Mortality remained constant at 0.50 per 10,000 (0.39-0.62) in 2003 and 0.42 per 10,000 (0.32-0.51) in 2015. (4) Conclusions: CTPA increased from 2003 to 2015, while diagnostic yield decreased, potentially indicating overtesting. PE mortality remained constant despite increasing hospitalizations, likely indicating a higher proportion of less severe cases. As treatment can be harmful, this could represent overdiagnosis.
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Thurlow LE, Van Dam PJ, Prior SJ, Tran V. Use of Computed Tomography Pulmonary Angiography in Emergency Departments: A Literature Review. Healthcare (Basel) 2022; 10:healthcare10050753. [PMID: 35627890 PMCID: PMC9140691 DOI: 10.3390/healthcare10050753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 04/12/2022] [Accepted: 04/15/2022] [Indexed: 02/04/2023] Open
Abstract
Computed tomography pulmonary angiography (CTPA) has become the most widely used technique for diagnosis or exclusion of a pulmonary embolism (PE). It has been suggested that overuse of this imaging type may be prevalent, especially in emergency departments (EDs). The purpose of this literature review was to explore the use of CTPAs in EDs worldwide. A review following PRISMA guidelines was completed, with research published between September 2010 and August 2020 included. Five key topics emerged: use of CTPAs; explanations for overuse; use of D-dimer; variability in ordering practices between clinicians; and strategies to reduce overuse. This review found that CTPAs continue to be overused in EDs, leading to superfluous risks to patients. Published studies identify that while clinical practice guidelines (CPGs) have a strong effect on reducing unnecessary CTPAs with no significantly increased risk of missed diagnosis, the adoption of these tools by ED clinicians has remained low. This literature review highlights the need for further research into why CTPAs continue to be overused within EDs and why clinicians are hesitant to use CPGs in the clinical setting. Moreover, investigations into other potential strategies that may combat the overuse of this diagnostic tool are essential to reduce potential harm.
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Affiliation(s)
- Lauren E. Thurlow
- Tasmanian School of Medicine, College of Health and Medicine, University of Tasmania, Hobart, TAS 7000, Australia;
- Correspondence:
| | - Pieter J. Van Dam
- School of Nursing, College of Health and Medicine, University of Tasmania, Burnie, TAS 7320, Australia;
| | - Sarah J. Prior
- Tasmanian School of Medicine, College of Health and Medicine, University of Tasmania, Burnie, TAS 7320, Australia;
| | - Viet Tran
- Tasmanian School of Medicine, College of Health and Medicine, University of Tasmania, Hobart, TAS 7000, Australia;
- Emergency Department, Royal Hobart Hospital, Hobart, TAS 7000, Australia
- Menzies Institute for Medical Research, University of Tasmania, Hobart, TAS 7000, Australia
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Salehi L, Phalpher P, Yu H, Jaskolka J, Ossip M, Meaney C, Valani R, Mercuri M. Utilization of serum D-dimer assays prior to computed tomography pulmonary angiography scans in the diagnosis of pulmonary embolism among emergency department physicians: a retrospective observational study. BMC Emerg Med 2021; 21:10. [PMID: 33468044 PMCID: PMC7814629 DOI: 10.1186/s12873-021-00401-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 01/04/2021] [Indexed: 01/15/2023] Open
Abstract
Background A variety of evidence-based algorithms and decision rules using D-Dimer testing have been proposed as instruments to allow physicians to safely rule out a pulmonary embolism (PE) in low-risk patients. Objective To describe the prevalence of D-Dimer utilization among emergency department (ED) physicians and its impact on positive yields and utilization rates of Computed Tomography Pulmonary Angiography (CTPA). Methods Data was collected on all CTPA studies ordered by ED physicians at three sites during a 2-year period. Using a chi-square test, we compared the diagnostic yield for those patients who had a D-Dimer prior to their CTPA and those who did not. Secondary analysis was done to examine the impact of D-Dimer testing prior to CTPA on individual physician diagnostic yield or utilization rate. Results A total of 2811 CTPAs were included in the analysis. Of these, 964 CTPAs (34.3%) were ordered without a D-Dimer, and 343 (18.7%) underwent a CTPA despite a negative D-Dimer. Those CTPAs preceded by a D-Dimer showed no significant difference in positive yields when compared to those ordered without a D-Dimer (9.9% versus 11.3%, p = 0.26). At the individual physician level, no statistically significant relationship was found between D-Dimer utilization and CTPA utilization rate or diagnostic yield. Conclusion This study provides evidence of suboptimal adherence to guidelines in terms of D-Dimer screening prior to CTPA, and forgoing CTPAs in patients with negative D-Dimers. However, the lack of a positive impact of D-Dimer testing on either CTPA diagnostic yield or utilization rate is indicative of issues relating to the high false-positive rates associated with D-Dimer screening.
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Affiliation(s)
- Leila Salehi
- Department of Family Medicine, McMaster University, 100 Main Street West, 6th floor, Hamilton, Ontario, Canada. .,Department of Family and Community Medicine, University of Toronto, 500 University Avenue, Toronto, Ontario, Canada. .,Department of Emergency Medicine, William Osler Health System, Suite S.1.184, 2100 Bovaird Avenue East, Brampton, Ontario, Canada.
| | - Prashant Phalpher
- Department of Family Medicine, McMaster University, 100 Main Street West, 6th floor, Hamilton, Ontario, Canada.,Department of Emergency Medicine, William Osler Health System, Suite S.1.184, 2100 Bovaird Avenue East, Brampton, Ontario, Canada
| | - Hubert Yu
- Department of Family and Community Medicine, University of Toronto, 500 University Avenue, Toronto, Ontario, Canada
| | - Jeffrey Jaskolka
- Department of Diagnostic Imaging, William Osler Health System, 2100 Bovaird Avenue East, Brampton, Ontario, Canada
| | - Marc Ossip
- Department of Diagnostic Imaging, William Osler Health System, 2100 Bovaird Avenue East, Brampton, Ontario, Canada
| | - Christopher Meaney
- Department of Family Medicine, McMaster University, 100 Main Street West, 6th floor, Hamilton, Ontario, Canada
| | - Rahim Valani
- Department of Emergency Medicine, William Osler Health System, Suite S.1.184, 2100 Bovaird Avenue East, Brampton, Ontario, Canada.,Division of Emergency Medicine, McMaster University, Hamilton Health Sciences, McMaster Clinic, 2nd floor, 237 Barton Street East, Hamilton, Ontario, Canada
| | - Mathew Mercuri
- Division of Emergency Medicine, McMaster University, Hamilton Health Sciences, McMaster Clinic, 2nd floor, 237 Barton Street East, Hamilton, Ontario, Canada
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Predictors of positive computed tomography pulmonary angiography results. Emerg Radiol 2020; 27:503-511. [DOI: 10.1007/s10140-020-01793-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 05/14/2020] [Indexed: 10/24/2022]
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