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Laffafchi S, Ebrahimi A, Kafan S. Efficient management of pulmonary embolism diagnosis using a two-step interconnected machine learning model based on electronic health records data. Health Inf Sci Syst 2024; 12:17. [PMID: 38464464 PMCID: PMC10917730 DOI: 10.1007/s13755-024-00276-9] [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: 12/15/2022] [Accepted: 01/17/2024] [Indexed: 03/12/2024] Open
Abstract
Pulmonary Embolism (PE) is a life-threatening clinical disease with no specific clinical symptoms and Computed Tomography Angiography (CTA) is used for diagnosis. Clinical decision support scoring systems like Wells and rGeneva based on PE risk factors have been developed to estimate the pre-test probability but are underused, leading to continuous overuse of CTA imaging. This diagnostic study aimed to propose a novel approach for efficient management of PE diagnosis using a two-step interconnected machine learning framework directly by analyzing patients' Electronic Health Records data. First, we performed feature importance analysis according to the result of LightGBM superiority for PE prediction, then four state-of-the-art machine learning methods were applied for PE prediction based on the feature importance results, enabling swift and accurate pre-test diagnosis. Throughout the study patients' data from different departments were collected from Sina educational hospital, affiliated with the Tehran University of medical sciences in Iran. Generally, the Ridge classification method obtained the best performance with an F1 score of 0.96. Extensive experimental findings showed the effectiveness and simplicity of this diagnostic process of PE in comparison with the existing scoring systems. The main strength of this approach centered on PE disease management procedures, which would reduce avoidable invasive CTA imaging and be applied as a primary prognosis of PE, hence assisting the healthcare system, clinicians, and patients by reducing costs and promoting treatment quality and patient satisfaction.
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Affiliation(s)
- Soroor Laffafchi
- Department of Business Administration and Entrepreneurship, Faculty of Management and Economics, Science and Research Branch, Islamic Azad University, Daneshgah Blvd, Simon Bulivar Blvd, Tehran, Iran
| | - Ahmad Ebrahimi
- Department of Industrial and Technology Management, Faculty of Management and Economics, Science and Research Branch, Islamic Azad University, Daneshgah Blvd, Simon Bulivar Blvd, Tehran, Iran
| | - Samira Kafan
- Department of Pulmonary Medicine, Sina Hospital, International Relations Office, Medical School, Tehran University of Medical Sciences, PourSina St., Tehran, 1417613151 Iran
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2
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Richardson S, Dauber-Decker KL, Solomon J, Seelamneni P, Khan S, Barnaby DP, Chelico J, Qiu M, Liu Y, Sanghani S, Izard SM, Chiuzan C, Mann D, Pekmezaris R, McGinn T, Diefenbach MA. Effect of a behavioral nudge on adoption of an electronic health record-agnostic pulmonary embolism risk prediction tool: a pilot cluster nonrandomized controlled trial. JAMIA Open 2024; 7:ooae064. [PMID: 39091509 PMCID: PMC11293639 DOI: 10.1093/jamiaopen/ooae064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2023] [Revised: 05/24/2024] [Accepted: 06/25/2024] [Indexed: 08/04/2024] Open
Abstract
Objective Our objective was to determine the feasibility and preliminary efficacy of a behavioral nudge on adoption of a clinical decision support (CDS) tool. Materials and Methods We conducted a pilot cluster nonrandomized controlled trial in 2 Emergency Departments (EDs) at a large academic healthcare system in the New York metropolitan area. We tested 2 versions of a CDS tool for pulmonary embolism (PE) risk assessment developed on a web-based electronic health record-agnostic platform. One version included behavioral nudges incorporated into the user interface. Results A total of 1527 patient encounters were included in the trial. The CDS tool adoption rate was 31.67%. Adoption was significantly higher for the tool that included behavioral nudges (39.11% vs 20.66%; P < .001). Discussion We demonstrated feasibility and preliminary efficacy of a PE risk prediction CDS tool developed using insights from behavioral science. The tool is well-positioned to be tested in a large randomized clinical trial. Trial Registration Clinicaltrials.gov (NCT05203185).
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Affiliation(s)
- Safiya Richardson
- New York University (NYU) Langone, New York, NY 10016, United States
| | | | - Jeffrey Solomon
- Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY 11030, United States
| | - Pradeep Seelamneni
- Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY 11030, United States
| | - Sundas Khan
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX 77030, United States
- Baylor College of Medicine, Houston, TX 77030, United States
| | - Douglas P Barnaby
- Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY 11030, United States
- Northwell/Zucker School of Medicine, Hempstead, NY 11549, United States
| | - John Chelico
- CommonSpirit Health, Chicago, IL 60606, United States
| | - Michael Qiu
- Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY 11030, United States
| | - Yan Liu
- Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY 11030, United States
| | - Shreya Sanghani
- Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY 11030, United States
| | - Stephanie M Izard
- Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY 11030, United States
| | - Codruta Chiuzan
- Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY 11030, United States
| | - Devin Mann
- New York University (NYU) Langone, New York, NY 10016, United States
| | - Renee Pekmezaris
- Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY 11030, United States
- Northwell/Zucker School of Medicine, Hempstead, NY 11549, United States
| | - Thomas McGinn
- Baylor College of Medicine, Houston, TX 77030, United States
- CommonSpirit Health, Chicago, IL 60606, United States
| | - Michael A Diefenbach
- Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY 11030, United States
- Northwell/Zucker School of Medicine, Hempstead, NY 11549, United States
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3
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Gu H, Li B, Han Y, Yang S, Wang X. Risk factors for suspected pulmonary embolism in children: Complication of Mycoplasma pneumoniae pneumonia. Eur J Radiol 2024; 176:111474. [PMID: 38696918 DOI: 10.1016/j.ejrad.2024.111474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 03/21/2024] [Accepted: 04/16/2024] [Indexed: 05/04/2024]
Abstract
PURPOSE Pulmonary embolism (PE) is not a rare complication of Mycoplasma pneumoniae pneumonia (MPP) in children. We sought to determine the incidence of PE in children with MPP who underwent clinically indicated CT pulmonary angiography (CTPA) and to evaluate the risk factors for PE. METHODS All 106 children with MPP who were clinically suspected of having PE and who underwent CTPA were retrospectively enrolled from June 2018 to December 2021. The clinical features, laboratory data, and radiological parameters were recorded (e.g., lung consolidation involved and the Qanadli score). A Cox proportional hazards model and area under the receiver operating characteristic (ROC) curve were used to evaluate the risk factors and prognostic discriminatory capacity for PE. RESULTS PE was detected in 26 of 106 (24.5 %) children (mean age, 6.2 years ± 3.3 years; 53 boys). Sixteen of the 26 (61.5 %) children with PE were boys. The mean age of the children with PE was 8.1 ± 2.9 years, and the mean Qanadli score was 15.3 ± 10.2. Children with PE had higher D-dimer levels (9.3 ± 7.1 mg/Lvs. 3.6 ± 3.8 mg/L) and a greater frequency of lung lobe consolidation (25 (96.2 %) vs. 64 (80.0 %)) (all P < 0.05). For children with MPP, age (hazard ratio (HR) = 1.96 (95 % CI1.04, 3.71; P = 0.037), D-dimer level (HR = 1.52, 95 % CI: 1.03, 2.24; P = 0.029), and bilateral lung consolidation (HR = 2.41, 95 % CI: 1.03, 5.58; P = 0.043) were found to be independent predictors of PE. CONCLUSION Clinical and CT radiological predictors could be used to predict PE in children with MPP. The use of risk factor assessment as a tool has the potential to guide more appropriate use of CTPA in children.
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Affiliation(s)
- Hui Gu
- Department of Radiology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, #324, Jingwu Road, Jinan, Shandong 250021, China
| | - Bowen Li
- Department of Radiology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, #324, Jingwu Road, Jinan, Shandong 250021, China
| | - Yicheng Han
- Department of Radiology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, #324, Jingwu Road, Jinan, Shandong 250021, China
| | - Shifeng Yang
- Department of Radiology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, #324, Jingwu Road, Jinan, Shandong 250021, China
| | - Ximing Wang
- Department of Radiology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, #324, Jingwu Road, Jinan, Shandong 250021, China.
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Altabbaa G, Flemons W, Ocampo W, Babione JN, Kaufman J, Murphy S, Lamont N, Schaefer J, Boscan A, Stelfox HT, Conly J, Ghali WA. Deployment of a human-centred clinical decision support system for pulmonary embolism: evaluation of impact on quality of diagnostic decisions. BMJ Open Qual 2024; 13:e002574. [PMID: 38350673 PMCID: PMC10862276 DOI: 10.1136/bmjoq-2023-002574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 01/25/2024] [Indexed: 02/15/2024] Open
Abstract
Pulmonary embolism (PE) is a serious condition that presents a diagnostic challenge for which diagnostic errors often happen. The literature suggests that a gap remains between PE diagnostic guidelines and adherence in healthcare practice. While system-level decision support tools exist, the clinical impact of a human-centred design (HCD) approach of PE diagnostic tool design is unknown. DESIGN Before-after (with a preintervention period as non-concurrent control) design study. SETTING Inpatient units at two tertiary care hospitals. PARTICIPANTS General internal medicine physicians and their patients who underwent PE workups. INTERVENTION After a 6-month preintervention period, a clinical decision support system (CDSS) for diagnosis of PE was deployed and evaluated over 6 months. A CDSS technical testing phase separated the two time periods. MEASUREMENTS PE workups were identified in both the preintervention and CDSS intervention phases, and data were collected from medical charts. Physician reviewers assessed workup summaries (blinded to the study period) to determine adherence to evidence-based recommendations. Adherence to recommendations was quantified with a score ranging from 0 to 1.0 (the primary study outcome). Diagnostic tests ordered for PE workups were the secondary outcomes of interest. RESULTS Overall adherence to diagnostic pathways was 0.63 in the CDSS intervention phase versus 0.60 in the preintervention phase (p=0.18), with fewer workups in the CDSS intervention phase having very low adherence scores. Further, adherence was significantly higher when PE workups included the Wells prediction rule (median adherence score=0.76 vs 0.59, p=0.002). This difference was even more pronounced when the analysis was limited to the CDSS intervention phase only (median adherence score=0.80 when Wells was used vs 0.60 when Wells was not used, p=0.001). For secondary outcomes, using both the D-dimer blood test (42.9% vs 55.7%, p=0.014) and CT pulmonary angiogram imaging (61.9% vs 75.4%, p=0.005) was lower during the CDSS intervention phase. CONCLUSION A clinical decision support intervention with an HCD improves some aspects of the diagnostic decision, such as the selection of diagnostic tests and the use of the Wells probabilistic prediction rule for PE.
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Affiliation(s)
- Ghazwan Altabbaa
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Ward Flemons
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Wrechelle Ocampo
- W21C Research and Innovation Centre, University of Calgary, Calgary, Alberta, Canada
| | | | - Jamie Kaufman
- W21C Research and Innovation Centre, University of Calgary, Calgary, Alberta, Canada
| | - Sydney Murphy
- W21C Research and Innovation Centre, University of Calgary, Calgary, Alberta, Canada
| | - Nicole Lamont
- W21C Research and Innovation Centre, University of Calgary, Calgary, Alberta, Canada
| | - Jeffrey Schaefer
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Alejandra Boscan
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Henry T Stelfox
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - John Conly
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - William A Ghali
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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5
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Gyftopoulos S, Simon E, Swartz JL, Smith SW, Martinez LS, Babb JS, Horwitz LI, Makarov DV. Efficacy and Impact of a Multimodal Intervention on CT Pulmonary Angiography Ordering Behavior in the Emergency Department. J Am Coll Radiol 2024; 21:309-318. [PMID: 37247831 DOI: 10.1016/j.jacr.2023.02.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 01/26/2023] [Accepted: 02/04/2023] [Indexed: 05/31/2023]
Abstract
OBJECTIVE To evaluate the efficacy of a multimodal intervention in reducing CT pulmonary angiography (CTPA) overutilization in the evaluation of suspected pulmonary embolism in the emergency department (ED). METHODS Previous mixed-methods analysis of barriers to guideline-concordant CTPA ordering results was used to develop a provider-focused behavioral intervention consisting of a clinical decision support tool and an audit and feedback system at a multisite, tertiary academic network. The primary outcome (guideline concordance) and secondary outcomes (yield and CTPA and D-dimer order rates) were compared using a pre- and postintervention design. ED encounters for adult patients from July 5, 2017, to January 3, 2019, were included. Fisher's exact tests and statistical process control charts were used to compare the pre- and postintervention groups for each outcome. RESULTS Of the 201,912 ED patient visits evaluated, 3,587 included CTPA. Guideline concordance increased significantly after the intervention, from 66.9% to 77.5% (P < .001). CTPA order rate and D-dimer order rate also increased significantly, from 17.1 to 18.4 per 1,000 patients (P = .035) and 30.6 to 37.3 per 1,000 patients (P < .001), respectively. Percent yield showed no significant change (12.3% pre- versus 10.8% postintervention; P = .173). Statistical process control analysis showed sustained special-cause variation in the postintervention period for guideline concordance and D-dimer order rates, temporary special-cause variation for CTPA order rates, and no special-cause variation for percent yield. CONCLUSION Our success in increasing guideline concordance demonstrates the efficacy of a mixed-methods, human-centered approach to behavior change. Given that neither of the secondary outcomes improved, our results may demonstrate potential limitations to the guidelines directing the ordering of CTPA studies and D-dimer ordering.
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Affiliation(s)
- Soterios Gyftopoulos
- Department of Radiology, NYU Grossman School of Medicine, New York, New York, and Department of Orthopedic Surgery, NYU Grossman School of Medicine, New York, New York; Chief of Radiology, NYU-Brooklyn.
| | - Emma Simon
- Department of Population Health, NYU Grossman School of Medicine, New York, New York, and Center for Healthcare Innovation and Delivery Science, NYU Grossman School of Medicine, New York, New York
| | - Jordan L Swartz
- Ronald O. Perelman Department of Emergency Medicine, NYU Grossman School of Medicine, New York, New York
| | - Silas W Smith
- Ronald O. Perelman Department of Emergency Medicine, NYU Grossman School of Medicine, New York, New York; and Chief, Division of Quality, Safety, and Practice Innovation, Institute for Innovations in Medical Education, NYU Langone Health, New York, New York
| | - Leticia Santos Martinez
- Department of Population Health, NYU Grossman School of Medicine, New York, New York, and Center for Healthcare Innovation and Delivery Science, NYU Grossman School of Medicine, New York, New York
| | - James S Babb
- Department of Radiology, NYU Grossman School of Medicine, New York, New York
| | - Leora I Horwitz
- Department of Population Health, NYU Grossman School of Medicine, New York, New York; Center for Healthcare Innovation and Delivery Science, NYU Grossman School of Medicine, New York, New York; and Department of Medicine, NYU Grossman School of Medicine, New York, New York. https://twitter.com/Leorahorwitzmd
| | - Danil V Makarov
- Department of Population Health, NYU Grossman School of Medicine, New York, New York; Department of Urology, NYU Grossman School of Medicine, New York, New York; and Department of Urology, VA New York Harbor Healthcare System, New York, New York. https://twitter.com/Dannymak76
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Roussel M, Bloom B, Taalba M, Choquet C, Douillet D, Fémy F, Marouk A, Gorlicki J, Gerlier C, Macrez R, Arnaud E, Bompard R, Montassier E, Hugli O, Czopik C, Eyer X, Benhamed A, Peyrony O, Chouihed T, Penaloza A, Marra A, Laribi S, Reuter PG, Behringer W, Douplat M, Guenezan J, Javaud N, Lucidarme O, Cachanado M, Aparicio-Monforte A, Freund Y. Temporal Trends in the Use of Computed Tomographic Pulmonary Angiography for Suspected Pulmonary Embolism in the Emergency Department : A Retrospective Analysis. Ann Intern Med 2023. [PMID: 37216659 DOI: 10.7326/m22-3116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/24/2023] Open
Abstract
BACKGROUND Recently, validated clinical decision rules have been developed that avoid unnecessary use of computed tomographic pulmonary angiography (CTPA) in patients with suspected pulmonary embolism (PE) in the emergency department (ED). OBJECTIVE To measure any resulting change in CTPA use for suspected PE. DESIGN Retrospective analysis. SETTING 26 European EDs in 6 countries. PATIENTS Patients with CTPA performed for suspected PE in the ED during the first 7 days of each odd month between January 2015 and December 2019. MEASUREMENTS The primary end points were the CTPAs done for suspected PE in the ED and the number of PEs diagnosed in the ED each year adjusted to an annual census of 100 000 ED visits. Temporal trends were estimated using generalized linear mixed regression models. RESULTS 8970 CTPAs were included (median age, 63 years; 56% female). Statistically significant temporal trends for more frequent use of CTPA (836 per 100 000 ED visits in 2015 vs. 1112 in 2019; P < 0.001), more diagnosed PEs (138 per 100 000 in 2015 vs. 164 in 2019; P = 0.028), a higher proportion of low-risk PEs (annual percent change [APC], 13.8% [95% CI, 2.6% to 30.1%]) with more ambulatory management (APC, 19.3% [CI, 4.1% to 45.1%]), and a lower proportion of intensive care unit admissions (APC, -8.9% [CI, -17.1% to -0.3%]) were observed. LIMITATION Data were limited to 7 days every 2 months. CONCLUSION Despite the recent validation of clinical decision rules to limit the use of CTPA, an increase in the CTPA rate along with more diagnosed PEs and especially low-risk PEs were instead observed. PRIMARY FUNDING SOURCE None specific for this study.
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Affiliation(s)
- Melanie Roussel
- Sorbonne Université, UMR Inserm 1166, IHU ICAN, Paris; Emergency Department, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France (M.R., Y.F.)
| | - Ben Bloom
- Emergency Department, Royal London Hospital, London, United Kingdom (B.B.)
| | - Mehdi Taalba
- Emergency Department, Rouen University Hospital, Rouen, France (M.T.)
| | - Christophe Choquet
- Emergency Department, Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, Paris, France (C. Choquet)
| | - Delphine Douillet
- Department of Emergency Medicine, University Hospital of Angers, Angers; and UNIV Angers, UMR MitoVasc CNRS 6215 INSERM 1083, Angers, France (D.D.)
| | - Florent Fémy
- Emergency Department, Hôpital Européen Georges-Pompidou, Assistance Publique-Hôpitaux de Paris, Université Paris Cite, Paris; and Toxicology and Chemical Risks Department, French Armed Forces Biomedical Institute, Brétigny-sur-Orge, France (F.F.)
| | - Alexis Marouk
- Emergency Department, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France (A. Marouk)
| | - Judith Gorlicki
- Emergency Department, Hôpital Avicenne, Assistance Publique-Hôpitaux de Paris, Bobigny, France (J. Golicki)
| | - Camille Gerlier
- Emergency Department, Hôpital Saint-Joseph, Paris, France (C.G.)
| | - Richard Macrez
- Emergency Department, CHU Caen Côte de Nacre, Normandie Université UNICAEN, INSERM PhIND Institut Blood and Brain, Caen, France (R.M.)
| | - Emilien Arnaud
- Department of Emergency Medicine, Amiens-Picardy University Hospital, Amiens, France (E.A.)
| | - Rudy Bompard
- Emergency Department, Hôpital Tenon, Assistance Publique-Hôpitaux de Paris, Paris, France (R.B.)
| | | | - Olivier Hugli
- Emergency Department, Lausanne University Hospital Emergency Care Service, Lausanne, Switzerland (O.H.)
| | - Charlotte Czopik
- Emergency Department, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris, Paris, France (C. Czopik)
| | - Xavier Eyer
- Emergency Department, Hôpital Lariboisière, Assistance Publique-Hôpitaux de Paris, Paris, France (X.E.)
| | - Axel Benhamed
- Emergency Department, Hospices Civils de Lyon, Lyon, France (A.B., M.D.)
| | - Olivier Peyrony
- Emergency Department, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris, Paris, France (O.P.)
| | - Tahar Chouihed
- Emergency Department, University Hospital of Nancy, Nancy, France (T.C.)
| | - Andrea Penaloza
- Emergency Department, Cliniques Universitaires Saint-Luc, Brussels, Belgium (A.P.)
| | - Alessio Marra
- Emergency Department, ASST Papa Giovanni XXIII, Bergamo, Italy (A. Marra)
| | - Said Laribi
- Tours University, Emergency Medicine Department, Tours University Hospital, Tours, France (S.L.)
| | - Paul-Georges Reuter
- Emergency Department, Hôpital Ambroise Paré, Assistance Publique-Hôpitaux de Paris, Boulogne; and Université Versailles-Saint Quentin en Yvelines, Boulogne, France (P.-G.R.)
| | - Wilhelm Behringer
- Department of Emergency Medicine, Medical University Vienna, Vienna General Hospital, Vienna, Austria (W.B.)
| | - Marion Douplat
- Emergency Department, Hospices Civils de Lyon, Lyon, France (A.B., M.D.)
| | - Jeremy Guenezan
- Emergency Department, University Hospital of Poitiers, Poitiers, France (J. Guenezen)
| | - Nicolas Javaud
- Emergency Department, Hôpital Louis-Mourier, Assistance Publique-Hôpitaux de Paris, Colombes; and Reference Center for Bradykinin Angiodema (CReAk), Université Paris Cite, Colombes, France (N.J.)
| | - Olivier Lucidarme
- Sorbonne Université, UMR Inserm 1166, IHU ICAN, Paris; and Sorbonne Université, CNRS, INSERM, Laboratoire d'Imagerie Biomédicale LIB, Paris, France (O.L.)
| | - Marine Cachanado
- Department of Clinical Pharmacology and Clinical Research Platform Paris-East (URCEST-CRC-CRB), Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris, Paris, France (M.C., A.A.)
| | - Ainhoa Aparicio-Monforte
- Department of Clinical Pharmacology and Clinical Research Platform Paris-East (URCEST-CRC-CRB), Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris, Paris, France (M.C., A.A.)
| | - Yonathan Freund
- Sorbonne Université, UMR Inserm 1166, IHU ICAN, Paris; Emergency Department, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France (M.R., Y.F.)
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7
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Leung T, Dauber-Decker K, Solomon J, Khan S, Barnaby D, Chelico J, Qiu M, Liu Y, Mann D, Pekmezaris R, McGinn T, Diefenbach M. Nudging Health Care Providers' Adoption of Clinical Decision Support: Protocol for the User-Centered Development of a Behavioral Economics-Inspired Electronic Health Record Tool. JMIR Res Protoc 2023; 12:e42653. [PMID: 36652293 PMCID: PMC9892982 DOI: 10.2196/42653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 10/21/2022] [Accepted: 10/25/2022] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND The improvements in care resulting from clinical decision support (CDS) have been significantly limited by consistently low health care provider adoption. Health care provider attitudes toward CDS, specifically psychological and behavioral barriers, are not typically addressed during any stage of CDS development, although they represent an important barrier to adoption. Emerging evidence has shown the surprising power of using insights from the field of behavioral economics to address psychological and behavioral barriers. Nudges are formal applications of behavioral economics, defined as positive reinforcement and indirect suggestions that have a nonforced effect on decision-making. OBJECTIVE Our goal is to employ a user-centered design process to develop a CDS tool-the pulmonary embolism (PE) risk calculator-for PE risk stratification in the emergency department that incorporates a behavior theory-informed nudge to address identified behavioral barriers to use. METHODS All study activities took place at a large academic health system in the New York City metropolitan area. Our study used a user-centered and behavior theory-based approach to achieve the following two aims: (1) use mixed methods to identify health care provider barriers to the use of an active CDS tool for PE risk stratification and (2) develop a new CDS tool-the PE risk calculator-that addresses behavioral barriers to health care providers' adoption of CDS by incorporating nudges into the user interface. These aims were guided by the revised Observational Research Behavioral Information Technology model. A total of 50 clinicians who used the original version of the tool were surveyed with a quantitative instrument that we developed based on a behavior theory framework-the Capability-Opportunity-Motivation-Behavior framework. A semistructured interview guide was developed based on the survey responses. Inductive methods were used to analyze interview session notes and audio recordings from 12 interviews. Revised versions of the tool were developed that incorporated nudges. RESULTS Functional prototypes were developed by using Axure PRO (Axure Software Solutions) software and usability tested with end users in an iterative agile process (n=10). The tool was redesigned to address 4 identified major barriers to tool use; we included 2 nudges and a default. The 6-month pilot trial for the tool was launched on October 1, 2021. CONCLUSIONS Clinicians highlighted several important psychological and behavioral barriers to CDS use. Addressing these barriers, along with conducting traditional usability testing, facilitated the development of a tool with greater potential to transform clinical care. The tool will be tested in a prospective pilot trial. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/42653.
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Affiliation(s)
| | | | - Jeffrey Solomon
- Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, United States
| | - Sundas Khan
- Baylor College of Medicine, Houston, TX, United States
| | - Douglas Barnaby
- Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, United States
| | | | - Michael Qiu
- Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, United States
| | - Yan Liu
- Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, United States
| | - Devin Mann
- New York University Grossman School of Medicine, New York, NY, United States
| | - Renee Pekmezaris
- Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, United States
| | - Thomas McGinn
- Baylor College of Medicine, Houston, TX, United States.,CommonSpirit Health, Chicago, IL, United States
| | - Michael Diefenbach
- Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, United States
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8
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Schiebler ML, Fain S, van Beek E. Vascular imaging of the lung: perspectives on current imaging methods. Br J Radiol 2022; 95:20200759. [PMID: 32795175 PMCID: PMC9153715 DOI: 10.1259/bjr.20200759] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
This commentary will discuss the use of advanced non-invasive imaging methodology for the pulmonary vascular system with special attention to a rubric for the imaging and clinical team to use for any particular clinical situation.
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Affiliation(s)
- Mark L. Schiebler
- Department of Radiology, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Sean Fain
- Department of Medical Physics, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Edwin van Beek
- SINAPSE Chair of Clinical Radiology, Director Edinburgh Imaging facility QMRI, Honorary Consultant Radiologist, NHS Lothian Health Board, CO.19 Edinburgh Imaging, Queen’s Medical Research Institute, Edinburgh Bioquarter, 47 Little France Crescent, Edinburgh EH16 4TJ, United Kingdom
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9
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Zhang NJ, Rameau P, Julemis M, Liu Y, Solomon J, Khan S, McGinn T, Richardson S. Automated Pulmonary Embolism Risk Assessment Using the Wells Criteria: Validation Study. JMIR Form Res 2022; 6:e32230. [PMID: 35225812 PMCID: PMC8922138 DOI: 10.2196/32230] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Revised: 12/05/2021] [Accepted: 12/27/2021] [Indexed: 01/23/2023] Open
Abstract
Background Computed tomography pulmonary angiography (CTPA) is frequently used in the emergency department (ED) for the diagnosis of pulmonary embolism (PE), while posing risk for contrast-induced nephropathy and radiation-induced malignancy. Objective We aimed to create an automated process to calculate the Wells score for pulmonary embolism for patients in the ED, which could potentially reduce unnecessary CTPA testing. Methods We designed an automated process using electronic health records data elements, including using a combinatorial keyword search method to query free-text fields, and calculated automated Wells scores for a sample of all adult ED encounters that resulted in a CTPA study for PE at 2 tertiary care hospitals in New York, over a 2-month period. To validate the automated process, the scores were compared to those derived from a 2-clinician chart review. Results A total of 202 ED encounters resulted in a completed CTPA to form the retrospective study cohort. Patients classified as “PE likely” by the automated process (126/202, 62%) had a PE prevalence of 15.9%, whereas those classified as “PE unlikely” (76/202, 38%; Wells score >4) had a PE prevalence of 7.9%. With respect to classification of the patient as “PE likely,” the automated process achieved an accuracy of 92.1% when compared with the chart review, with sensitivity, specificity, positive predictive value, and negative predictive value of 93%, 90.5%, 94.4%, and 88.2%, respectively. Conclusions This was a successful development and validation of an automated process using electronic health records data elements, including free-text fields, to classify risk for PE in ED visits.
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Affiliation(s)
| | | | | | - Yan Liu
- Northwell Health, Manhasset, NY, United States
| | | | - Sundas Khan
- Northwell Health, Manhasset, NY, United States
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10
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Richardson S, Dauber-Decker KL, McGinn T, Barnaby DP, Cattamanchi A, Pekmezaris R. Barriers to the Use of Clinical Decision Support for the Evaluation of Pulmonary Embolism: Qualitative Interview Study. JMIR Hum Factors 2021; 8:e25046. [PMID: 34346901 PMCID: PMC8374661 DOI: 10.2196/25046] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 02/05/2021] [Accepted: 04/05/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Clinicians often disregard potentially beneficial clinical decision support (CDS). OBJECTIVE In this study, we sought to explore the psychological and behavioral barriers to the use of a CDS tool. METHODS We conducted a qualitative study involving emergency medicine physicians and physician assistants. A semistructured interview guide was created based on the Capability, Opportunity, and Motivation-Behavior model. Interviews focused on the barriers to the use of a CDS tool built based on Wells' criteria for pulmonary embolism to assist clinicians in establishing pretest probability of pulmonary embolism before imaging. RESULTS Interviews were conducted with 12 clinicians. Six barriers were identified, including (1) Bayesian reasoning, (2) fear of missing a pulmonary embolism, (3) time pressure or cognitive load, (4) gestalt includes Wells' criteria, (5) missed risk factors, and (6) social pressure. CONCLUSIONS Clinicians highlighted several important psychological and behavioral barriers to CDS use. Addressing these barriers will be paramount in developing CDS that can meet its potential to transform clinical care.
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Affiliation(s)
- Safiya Richardson
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, United States
| | | | - Thomas McGinn
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, United States
| | - Douglas P Barnaby
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, United States
| | - Adithya Cattamanchi
- Division of Pulmonary and Critical Care Medicine and Partnerships for Research in Implementation Science for Equity (PRISE) Center, University of California San Francisco, San Francisco, CA, United States
| | - Renee Pekmezaris
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, United States
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11
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Douillet D, Roy PM, Penaloza A. Suspected Acute Pulmonary Embolism: Gestalt, Scoring Systems, and Artificial Intelligence. Semin Respir Crit Care Med 2021; 42:176-182. [PMID: 33592653 DOI: 10.1055/s-0041-1723936] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Pulmonary embolism (PE) remains a diagnostic challenge in 2021. As the pathology is potentially fatal and signs and symptoms are nonspecific, further investigations are classically required. Based on the Bayesian approach, clinical probability became the keystone of the diagnostic strategy to rule out PE in the case of a negative testing. Several clinical probability assessment methods are validated: gestalt, the Wells score, or the revised Geneva score. While the debate persists as to the best way to assess clinical probability, its assessment allows for the good interpretation of the investigation results and therefore directs the correct diagnostic strategy. The wide availability of computed tomography pulmonary angiography (CTPA) resulted in a major increase in investigations with a moderate increase in diagnosis, without any notable improvement in patient outcomes. This leads to a new challenge for PE diagnosis which is the limitation of the number of testing for suspected PE. We review different strategies recently developed to achieve this goal. The last challenge concerns the implementation in clinical practice. Two approaches are developed: simplification of the strategies versus the use of digital support tools allowing more sophisticated strategies. Artificial intelligence with machine-learning algorithms will probably be a future tool to guide the physician in this complex approach concerning acute PE suspicion.
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Affiliation(s)
- Delphine Douillet
- Emergency Department, Angers University Hospital, INSERM 1083, Health Faculty, UNIV Angers, F-CRIN INNOVTE, Angers, France
| | - Pierre-Marie Roy
- Emergency Department, Angers University Hospital, INSERM 1083, Health Faculty, UNIV Angers, F-CRIN INNOVTE, Angers, France
| | - Andrea Penaloza
- Emergency Department, Cliniques Universitaires Saint Luc, UCLouvain, F-CRIN INNOVTE, Brussels, Belgium
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12
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Zarabi S, Chan TM, Mercuri M, Kearon C, Turcotte M, Grusko E, Barbic D, Varner C, Bridges E, Houston R, Eagles D, de Wit K. Physician choices in pulmonary embolism testing. CMAJ 2021; 193:E38-E46. [PMID: 33431544 PMCID: PMC7773048 DOI: 10.1503/cmaj.201639] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/25/2020] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Evidence-based guidelines advise excluding pulmonary embolism (PE) diagnosis using d-dimer in patients with a lower probability of PE. Emergency physicians frequently order computed tomography (CT) pulmonary angiography without d-dimer testing or when d-dimer is negative, which exposes patients to more risk than benefit. Our objective was to develop a conceptual framework explaining emergency physicians' test choices for PE. METHODS We conducted a qualitative study using in-depth interviews of emergency physicians in Canada. A nonmedical researcher conducted in-person interviews. Participants described how they would test simulated patients with symptoms of possible PE, answered a knowledge test and were interviewed on barriers to using evidence-based PE tests. RESULTS We interviewed 63 emergency physicians from 9 hospitals in 5 cities, across 3 provinces. We identified 8 domains: anxiety with PE, barriers to using the evidence (time, knowledge and patient), divergent views on evidence-based PE testing, inherent Wells score problems, the drive to obtain CT rather than to diagnose PE, gestalt estimation artificially inflating PE probability, subjective reasoning and cognitive biases supporting deviation from evidence-based tests and use of evidence-based testing to rule out PE in patients who are very unlikely to have PE. Choices for PE testing were influenced by the disease, environment, test qualities, physician and probability of PE. INTERPRETATION Analysis of structured interviews with emergency physicians provided a conceptual framework to explain how these physicians use tests for suspected PE. The data suggest 8 domains to address when implementing an evidence-based protocol to investigate PE.
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Affiliation(s)
- Sahar Zarabi
- Faculty 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
| | - Teresa M Chan
- Faculty 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
| | - Mathew Mercuri
- Faculty 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
| | - Clive Kearon
- Faculty 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
| | - Michelle Turcotte
- Faculty 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
| | - Emily Grusko
- Faculty 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
| | - David Barbic
- Faculty 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
| | - Catherine Varner
- Faculty 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
| | - Eileen Bridges
- Faculty 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
| | - Reaves Houston
- Faculty 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
| | - Debra Eagles
- Faculty 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
| | - Kerstin de Wit
- Faculty 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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13
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Wang RC, Miglioretti DL, Marlow EC, Kwan ML, Theis MK, Bowles EJA, Greenlee RT, Rahm AK, Stout NK, Weinmann S, Smith-Bindman R. Trends in Imaging for Suspected Pulmonary Embolism Across US Health Care Systems, 2004 to 2016. JAMA Netw Open 2020; 3:e2026930. [PMID: 33216141 PMCID: PMC7679949 DOI: 10.1001/jamanetworkopen.2020.26930] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
IMPORTANCE In response to calls to reduce unnecessary diagnostic testing with computed tomographic pulmonary angiography (CTPA) for suspected pulmonary embolism (PE), there have been growing efforts to create and implement decision rules for PE testing. It is unclear if the use of advanced imaging tests for PE has diminished over time. OBJECTIVE To assess the use of advanced imaging tests, including chest computed tomography (CT) (ie, all chest CT except for CTPA), CTPA, and ventilation-perfusion (V/Q) scan, for PE from 2004 to 2016. DESIGN, SETTING, AND PARTICIPANTS Cohort study of adults by age group (18-64 years and ≥65 years) enrolled in 7 US integrated and mixed-model health care systems. Joinpoint regression analysis was used to identify years with statistically significant changes in imaging rates and to calculate average annual percentage change (growth) from 2004 to 2007, 2008 to 2011, and 2012 to 2016. Analyses were conducted between June 11, 2019, and March 18, 2020. MAIN OUTCOMES AND MEASURES Rates of chest CT, CTPA, and V/Q scan by year and age, as well as annual change in rates over time. RESULTS Overall, 3.6 to 4.8 million enrollees were included each year of the study, for a total of 52 343 517 person-years of follow-up data. Adults aged 18 to 64 years accounted for 42 223 712 person-years (80.7%) and those 65 years or older accounted for 10 119 805 person-years (19.3%). Female enrollees accounted for 27 712 571 person-years (52.9%). From 2004 and 2016, chest CT use increased by 66.3% (average annual growth, 4.4% per year), CTPA use increased by 450.0% (average annual growth, 16.3% per year), and V/Q scan use decreased by 47.1% (decreasing by 4.9% per year). The use of CTPA increased most rapidly from 2004 to 2006 (44.6% in those aged 18-64 years and 43.9% in those ≥65 years), with ongoing rapid growth from 2006 to 2010 (annual growth, 19.8% in those aged 18-64 years and 18.3% in those ≥65 years) and persistent but slower growth in the most recent years (annual growth, 4.3% in those aged 18-64 years and 3.0% in those ≥65 years from 2010 to 2016). The use of V/Q scanning decreased steadily since 2004. CONCLUSIONS AND RELEVANCE From 2004 to 2016, rates of chest CT and CTPA for suspected PE continued to increase among adults but at a slower pace in more contemporary years. Efforts to combat overuse have not been completely successful as reflected by ongoing growth, rather than decline, of chest CT use. Whether the observed imaging use was appropriate or was associated with improved patient outcomes is unknown.
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Affiliation(s)
- Ralph C. Wang
- Department of Emergency Medicine, University of California, San Francisco
| | - Diana L. Miglioretti
- Department of Public Health Sciences, University of California, Davis
- Comprehensive Cancer Center, University of California, Davis
- Kaiser Permanente Washington Health Research Institute, Kaiser Permanente Washington, Seattle
| | - Emily C. Marlow
- Department of Public Health Sciences, University of California, Davis
| | - Marilyn L. Kwan
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - May K. Theis
- Kaiser Permanente Washington Health Research Institute, Kaiser Permanente Washington, Seattle
| | - Erin J. A. Bowles
- Kaiser Permanente Washington Health Research Institute, Kaiser Permanente Washington, Seattle
| | - Robert T. Greenlee
- Marshfield Clinic Research Institute, Marshfield Clinic Health System, Marshfield, Wisconsin
| | - Alanna K. Rahm
- Genomic Medicine Institute, Geisinger, Danville, Pennsylvania
| | - Natasha K. Stout
- Massachusetts Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston
| | - Sheila Weinmann
- now with Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon
- Center for Integrated Health Research, Kaiser Permanente Hawaii, Honolulu
| | - Rebecca Smith-Bindman
- Department of Radiology and Biomedical Imaging, University of California, San Francisco
- Department of Epidemiology and Biostatistics, University of California, San Francisco
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco
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14
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Kornblum J, Daugherty RJ, Bounds R, Vance AZ, Graif A. Diagnostic yield of computed tomographic pulmonary angiography for suspected pulmonary embolism varies across settings within a community-based health system. Emerg Radiol 2020; 28:291-296. [PMID: 33000363 DOI: 10.1007/s10140-020-01858-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Accepted: 09/27/2020] [Indexed: 11/26/2022]
Abstract
PURPOSE The diagnostic yield of computed tomographic pulmonary angiography (CTPA) for pulmonary embolism varies in the literature, and very little data is available regarding community-based systems. This study evaluates the yield of CTPA for pulmonary embolism across a variety of patient care settings in a community-based healthcare system, providing relevant benchmarks for potential quality improvement efforts. METHODS This retrospective study included data collected from three sites within a single community-based healthcare system, including a tertiary care level 1 trauma center, an urban community hospital, and a suburban free-standing emergency department. CTPAs were identified by Current Procedural Terminology codes, and diagnoses of pulmonary embolism were identified via International Classification of Diseases codes. A total of 7850 CTPA studies met criteria for inclusion between January 1, 2012, and October 8, 2014. RESULTS Pulmonary embolism was found in 884 (11.3%) of the studies performed. Outpatients had a lower yield of pulmonary embolism (3.8%, p < 0.001) compared with inpatients (14.1%) and emergency department patients (10.7%, p < 0.001). Patients with diagnoses of deep vein thrombosis or neoplasm had increased incidence of pulmonary embolism when compared with patients without these diagnoses (p < 0.001 for both). CONCLUSION The overall yield of CTPA for pulmonary embolism in this community-based system was similar to that at academic centers. The yield was significantly lower in the outpatient setting compared with studies originating in the emergency department or inpatient setting.
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Affiliation(s)
- Joshua Kornblum
- Department of Diagnostic Radiology, ChristianCare Health System, Newark, DE, USA
| | - Reza J Daugherty
- Department of Medical Imaging, Division of Pediatric Radiology, University of Virginia, Charlottesville, VA, USA
| | - Richard Bounds
- Division of Emergency Medicine, Department of Surgery, University of Vermont Medical Center, Burlington, VT, USA
| | - Ansar Z Vance
- Division of Interventional Radiology, Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Assaf Graif
- Department of Vascular and Interventional Radiology, ChristianaCare Health System, 4755 Ogletown-Stanton Rd., Ste 1E20, Newark, DE, 19718, USA.
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15
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Babione JN, Ocampo W, Haubrich S, Yang C, Zuk T, Kaufman J, Carpendale S, Ghali W, Altabbaa G. Human-centred design processes for clinical decision support: A pulmonary embolism case study. Int J Med Inform 2020; 142:104196. [DOI: 10.1016/j.ijmedinf.2020.104196] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 05/19/2020] [Accepted: 05/22/2020] [Indexed: 12/30/2022]
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16
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Rawal H, Ipaye O, Kalaria AD, Vij R, Dubin JS, Camire L, Weisman DS. High Scan Volume with Low Positive Scan Rate in Highest Utilizers: Computed Tomography Pulmonary Angiography in the Emergency Department. J Emerg Med 2020; 59:21-24. [PMID: 32381340 DOI: 10.1016/j.jemermed.2020.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Revised: 03/16/2020] [Accepted: 04/08/2020] [Indexed: 06/11/2023]
Abstract
BACKGROUND We examined utilization patterns and predictors of computed tomography pulmonary angiography (CTPA) results in the emergency department (ED). OBJECTIVES We retrospectively determined ED CTPA positive scan rate (PSR) among ED attendings based on a system that grouped attendings into scan quantity categories through >100. METHODS We manually reviewed all scans ordered in 2017 in EDs in a multisite medical system. RESULTS Of 10,032 ED CTPAs, 6168 were ordered by 153 ED attendings. Most attendings (123/153; 80%) ordered 60 or fewer scans with relatively high PSR (259/2927, PSR 8.8%; 95% confidence interval 7.8-9.9%). Of the ED attendings, 13 (3%) ordered more than 100 scans each (1981 scans; 32% of all scans), with PSR of 5.5% (95% confidence interval 4.5-6.5%). CONCLUSION Most ED attendings were low- to mid-volume utilizers of CTPA and had a relatively high PSR. However, the small percentage of attendings who ordered more than 100 scans each accounted for a large percentage of the total scan volume and had a relatively low PSR. These findings suggest that sharing of performance feedback and best practices in the highest utilizers could help to improve CTPA PSR in the ED.
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Affiliation(s)
- Himanshu Rawal
- MedStar Good Samaritan Hospital, Baltimore, Maryland; MedStar Union Memorial Hospital, Baltimore, Maryland
| | - Oluwatoyosi Ipaye
- MedStar Good Samaritan Hospital, Baltimore, Maryland; Georgetown University School of Medicine, Washington, DC
| | | | - Radhika Vij
- MedStar Union Memorial Hospital, Baltimore, Maryland
| | | | - Lyn Camire
- MedStar Good Samaritan Hospital, Baltimore, Maryland; MedStar Union Memorial Hospital, Baltimore, Maryland
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17
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Westafer LM, Kunz A, Bugajska P, Hughes A, Mazor KM, Schoenfeld EM, Stefan MS, Lindenauer PK. Provider Perspectives on the Use of Evidence-based Risk Stratification Tools in the Evaluation of Pulmonary Embolism: A Qualitative Study. Acad Emerg Med 2020; 27:447-456. [PMID: 32220127 PMCID: PMC7418048 DOI: 10.1111/acem.13908] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Revised: 11/19/2019] [Accepted: 12/16/2019] [Indexed: 12/18/2022]
Abstract
OBJECTIVES Providers often pursue imaging in patients at low risk of pulmonary embolism (PE), resulting in imaging yields <10% and false-positive imaging rates of 10% to 25%. Attempts to curb overtesting have had only modest success and no interventions have used implementation science frameworks. The objective of this study was to identify barriers and facilitators to the adoption of evidence-based diagnostic testing for PE. METHODS We conducted semistructured interviews with a purposeful sample of providers. An interview guide was developed using the implementation science frameworks, consolidated framework for implementation research, and theoretical domains framework. Interviews were recorded, transcribed, and analyzed in an iterative process. Emergent themes were identified, discussed, and organized. RESULTS We interviewed 23 providers from four hospital systems, and participants were diverse with regard to years in practice and practice setting. Barriers were predominately at the provider level and included lack of knowledge of the tools, particularly misunderstanding of the validated scoring systems in Wells, as well as risk avoidance and need for certainty. Barriers to prior implementation strategies included the perception of a clinical decision support (CDS) tool for PE as adding steps with little value; most participants reported that they overrode CDS interventions because they had already made the decision. All providers identified institution-level strategies as facilitators to use, including endorsed guidelines, audit feedback with peer comparison about imaging yield, and peer pressure. CONCLUSIONS This exploration of the use of risk stratification tools in the evaluation of PE found that barriers to use primarily exist at the provider level, whereas facilitators to the use of these tools are largely perceived at the level of the institution. Future efforts to promote the evidence-based diagnosis of PE should be informed by these determinants.
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Affiliation(s)
- Lauren M Westafer
- From the, Department of Emergency Medicine, University of Massachusetts Medical School-Baystate, Springfield, MA
- the, Institute for Healthcare Delivery and Population Science, University of Massachusetts Medical School-Baystate, Springfield, MA
| | - Ashley Kunz
- From the, Department of Emergency Medicine, University of Massachusetts Medical School-Baystate, Springfield, MA
| | | | - Amber Hughes
- University of Massachusetts Amherst, Amherst, MA
| | - Kathleen M Mazor
- Meyers Primary Care Institute, Worcester, MA
- and the, Department of Medicine, University of Massachusetts Medical School, Worcester, MA
| | - Elizabeth M Schoenfeld
- From the, Department of Emergency Medicine, University of Massachusetts Medical School-Baystate, Springfield, MA
- the, Institute for Healthcare Delivery and Population Science, University of Massachusetts Medical School-Baystate, Springfield, MA
| | - Mihaela S Stefan
- the, Institute for Healthcare Delivery and Population Science, University of Massachusetts Medical School-Baystate, Springfield, MA
- and the, Department of Medicine, University of Massachusetts Medical School-Baystate, Springfield, MA
| | - Peter K Lindenauer
- the, Institute for Healthcare Delivery and Population Science, University of Massachusetts Medical School-Baystate, Springfield, MA
- and the, Department of Medicine, University of Massachusetts Medical School-Baystate, Springfield, MA
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18
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Predictors of Overtesting in Pulmonary Embolism Diagnosis. Acad Radiol 2020; 27:404-408. [PMID: 31155486 DOI: 10.1016/j.acra.2019.04.018] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 04/05/2019] [Accepted: 04/06/2019] [Indexed: 11/22/2022]
Abstract
BACKGROUND The benefits of computed tomography pulmonary angiography (CTPA) for pulmonary embolism (PE) diagnosis must be weighed against its risks, radiation-induced malignancy, and contrast-induced nephropathy. Appropriate use of CTPA can be assessed by monitoring yield, the percentage of tests positive for PE. We identify factors that are associated low CTPA yield, which may predict overtesting. METHODS This was a retrospective cohort study of six emergency departments between June 2014 and February 2017. The electronic health record was queried for CTPAs ordered for adult patients in the emergency department. We assessed the following patient factors: age, gender, body mass index, number of comorbidities, race, and ethnicity, provider factors: type (resident, fellow, attending, physician assistant) and environment factors: test time of day, season of visit, and crowdedness of the department. RESULTS A total of 14,782 CTPAs were reviewed, of which 1366 were found to be positive for PE, resulting in an overall CTPA yield of 9.24%. Provider type was not associated with a difference in yield. Testing was less likely to be positive in younger patients, females, those with lower body mass indexes and those identifying as Asian or Hispanic. Testing was also less likely to be positive when ordered during the overnight shift and during the winter and spring seasons. CONCLUSION Our study identified several patient and environmental factors associated with low CTPA yield suggesting potential targets for overtesting. Targeting education and clinical decision support to assist providers in these circumstances may meaningfully improve yields.
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Underuse of Clinical Decision Rules and d-Dimer in Suspected Pulmonary Embolism: A Nationwide Survey of the Veterans Administration Healthcare System. J Am Coll Radiol 2020; 17:405-411. [DOI: 10.1016/j.jacr.2019.10.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Revised: 09/29/2019] [Accepted: 10/03/2019] [Indexed: 12/19/2022]
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20
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Higher Imaging Yield When Clinical Decision Support Is Used. J Am Coll Radiol 2019; 17:496-503. [PMID: 31899178 DOI: 10.1016/j.jacr.2019.11.021] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Revised: 11/05/2019] [Accepted: 11/20/2019] [Indexed: 01/16/2023]
Abstract
OBJECTIVE Increased utilization of CT pulmonary angiography (CTPA) for the evaluation of pulmonary embolism has been associated with decreasing diagnostic yields and rising concerns about the harms of unnecessary testing. The objective of this study was to determine whether clinical decision support (CDS) use would be associated with increased imaging yields after controlling for selection bias. METHODS We performed a retrospective cohort study in the emergency departments of two tertiary care hospitals of all CTPAs performed between August 2015 and September 2018. Providers ordering a CTPA are routed to an optional CDS tool, which allows them to use Wells' Criteria for pulmonary embolism. After propensity score matching, CTPA yield was calculated for the CDS-use and CDS-dismissal groups and stratified by provider type. RESULTS A total of 7,367 CTPAs were ordered during the study period. Of those, providers used the CDS tool in 2,568 (35%) cases and did not use the tool in 4,799 (65%) of cases. After propensity score matching, CTPA yield was 11.99% in the CDS-use group and 8.70% in the CDS-dismissal group (P < .001). Attending physicians, residents, and physician assistant CDS users demonstrated a 56.5% (P = .006), 38.7% (P = .01), and 16.7% (P = .03) increased yield compared with those who dismissed the tool, respectively. DISCUSSION Diagnostic yield was 38% higher for CTPAs when the provider used the CDS tool, after controlling for selection bias. Yields were higher for every provider type. Further research is needed to discover successful strategies to increase provider use of these important tools.
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Ferguson C, Low G, Fung C. Retrospective Analysis of the Computed Tomography Pulmonary Angiogram Utilization Patterns in the Emergency Department. Can Assoc Radiol J 2019; 70:388-393. [PMID: 31540752 DOI: 10.1016/j.carj.2019.06.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Revised: 04/13/2019] [Accepted: 06/09/2019] [Indexed: 01/21/2023] Open
Abstract
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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Affiliation(s)
- Craig Ferguson
- Department of Radiology and Diagnostic Imaging, University of Alberta, University of Alberta Hospital, Edmonton, Alberta, Canada.
| | - Gavin Low
- Department of Radiology and Diagnostic Imaging, University of Alberta, University of Alberta Hospital, Edmonton, Alberta, Canada
| | - Christopher Fung
- Department of Radiology and Diagnostic Imaging, University of Alberta, University of Alberta Hospital, Edmonton, Alberta, Canada
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22
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Banerjee I, Sofela M, Yang J, Chen JH, Shah NH, Ball R, Mushlin AI, Desai M, Bledsoe J, Amrhein T, Rubin DL, Zamanian R, Lungren MP. Development and Performance of the Pulmonary Embolism Result Forecast Model (PERFORM) for Computed Tomography Clinical Decision Support. JAMA Netw Open 2019; 2:e198719. [PMID: 31390040 PMCID: PMC6686780 DOI: 10.1001/jamanetworkopen.2019.8719] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
IMPORTANCE Pulmonary embolism (PE) is a life-threatening clinical problem, and computed tomographic imaging is the standard for diagnosis. Clinical decision support rules based on PE risk-scoring models have been developed to compute pretest probability but are underused and tend to underperform in practice, leading to persistent overuse of CT imaging for PE. OBJECTIVE To develop a machine learning model to generate a patient-specific risk score for PE by analyzing longitudinal clinical data as clinical decision support for patients referred for CT imaging for PE. DESIGN, SETTING, AND PARTICIPANTS In this diagnostic study, the proposed workflow for the machine learning model, the Pulmonary Embolism Result Forecast Model (PERFORM), transforms raw electronic medical record (EMR) data into temporal feature vectors and develops a decision analytical model targeted toward adult patients referred for CT imaging for PE. The model was tested on holdout patient EMR data from 2 large, academic medical practices. A total of 3397 annotated CT imaging examinations for PE from 3214 unique patients seen at Stanford University hospitals and clinics were used for training and validation. The models were externally validated on 240 unique patients seen at Duke University Medical Center. The comparison with clinical scoring systems was done on randomly selected 100 outpatient samples from Stanford University hospitals and clinics and 101 outpatient samples from Duke University Medical Center. MAIN OUTCOMES AND MEASURES Prediction performance of diagnosing acute PE was evaluated using ElasticNet, artificial neural networks, and other machine learning approaches on holdout data sets from both institutions, and performance of models was measured by area under the receiver operating characteristic curve (AUROC). RESULTS Of the 3214 patients included in the study, 1704 (53.0%) were women from Stanford University hospitals and clinics; mean (SD) age was 60.53 (19.43) years. The 240 patients from Duke University Medical Center used for validation included 132 women (55.0%); mean (SD) age was 70.2 (14.2) years. In the samples for clinical scoring system comparisons, the 100 outpatients from Stanford University hospitals and clinics included 67 women (67.0%); mean (SD) age was 57.74 (19.87) years, and the 101 patients from Duke University Medical Center included 59 women (58.4%); mean (SD) age was 73.06 (15.3) years. The best-performing model achieved an AUROC performance of predicting a positive PE study of 0.90 (95% CI, 0.87-0.91) on intrainstitutional holdout data with an AUROC of 0.71 (95% CI, 0.69-0.72) on an external data set from Duke University Medical Center; superior AUROC performance and cross-institutional generalization of the model of 0.81 (95% CI, 0.77-0.87) and 0.81 (95% CI, 0.73-0.82), respectively, were noted on holdout outpatient populations from both intrainstitutional and extrainstitutional data. CONCLUSIONS AND RELEVANCE The machine learning model, PERFORM, may consider multitudes of applicable patient-specific risk factors and dependencies to arrive at a PE risk prediction that generalizes to new population distributions. This approach might be used as an automated clinical decision-support tool for patients referred for CT PE imaging to improve CT use.
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Affiliation(s)
- Imon Banerjee
- Department of Biomedical Data Science, Stanford University, Stanford, California
- Department of Radiology, Stanford University, Stanford, California
| | - Miji Sofela
- Duke University Health System, Duke University School of Medicine, Durham, North Carolina
| | - Jaden Yang
- Quantitative Science Unit, Stanford University, Stanford, California
| | - Jonathan H. Chen
- Department of Medicine (Biomedical Informatics), Stanford University, Stanford, California
| | - Nigam H. Shah
- Department of Medicine (Biomedical Informatics), Stanford University, Stanford, California
| | - Robyn Ball
- Quantitative Science Unit, Stanford University, Stanford, California
| | - Alvin I. Mushlin
- Department of Medicine, Weill Cornell Medical College, Cornell University, Ithaca, New York
| | - Manisha Desai
- Quantitative Science Unit, Stanford University, Stanford, California
| | - Joseph Bledsoe
- Department of Emergency Medicine, Intermountain Medical Center, Salt Lake City, Utah
| | - Timothy Amrhein
- Department of Radiology, Duke University School of Medicine, Durham, North Carolina
| | - Daniel L. Rubin
- Department of Biomedical Data Science, Stanford University, Stanford, California
- Department of Radiology, Stanford University, Stanford, California
| | - Roham Zamanian
- Department of Medicine, Med/Pulmonary, and Critical Care Medicine, Stanford University, Stanford, California
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Klil-Drori AJ, Prajapati D, Liang Z, Wang M, Toupin D, Alothman L, Lang E, Suryanarayan D, Tagalakis V. External Validation of ASPECT (Algorithm for Suspected Pulmonary Embolism Confirmation and Treatment). Med Care 2019; 57:e47-e52. [DOI: 10.1097/mlr.0000000000001055] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Kocher KE, Arora R, Bassin BS, Benjamin LS, Bolton M, Dennis BJ, Ham JJ, Krupp SS, Levasseur KA, Macy ML, O'Neil BJ, Pribble JM, Sherwin RL, Sroufe NS, Uren BJ, Nypaver MM. Baseline Performance of Real-World Clinical Practice Within a Statewide Emergency Medicine Quality Network: The Michigan Emergency Department Improvement Collaborative (MEDIC). Ann Emerg Med 2019; 75:192-205. [PMID: 31256906 DOI: 10.1016/j.annemergmed.2019.04.033] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Revised: 03/11/2019] [Accepted: 04/25/2019] [Indexed: 11/30/2022]
Abstract
STUDY OBJECTIVE Large-scale quality and performance measurement across unaffiliated hospitals is an important strategy to drive practice change. The Michigan Emergency Department Improvement Collaborative (MEDIC), established in 2015, has baseline performance data to identify practice variation across 15 diverse emergency departments (EDs) on key emergency care quality indicators. METHODS MEDIC is a unique physician-led partnership supported by a major third-party payer. Member sites contribute electronic health record data and trained abstractors add supplementary data for eligible cases. Quality measures include computed tomography (CT) appropriateness for minor head injury, using the Canadian CT Head Rule for adults and Pediatric Emergency Care Applied Network rules for children; chest radiograph use for children with asthma, bronchiolitis, and croup; and diagnostic yield of CTs for suspected pulmonary embolism. Baseline performance was established with statistical process control charts. RESULTS From June 1, 2016, to October 31, 2017, the MEDIC registry contained 1,124,227 ED visits, 23.2% for children (<18 years). Overall baseline performance included the following: 40.9% of adult patients with minor head injury (N=11,857) had appropriate CTs (site range 24.3% to 58.6%), 10.3% of pediatric minor head injury cases (N=11,183) exhibited CT overuse (range 5.8% to 16.8%), 38.1% of pediatric patients with a respiratory condition (N=18,190) received a chest radiograph (range 9.0% to 62.1%), and 8.7% of pulmonary embolism CT results (N=16,205) were positive (range 7.5% to 14.3%). CONCLUSION Performance varied greatly, with demonstrated opportunity for improvement. MEDIC provides a robust platform for emergency physician engagement across ED practice settings to improve care and is a model for other states.
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Affiliation(s)
- Keith E Kocher
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI; Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI.
| | - Rajan Arora
- Department of Emergency Medicine and Pediatrics, Wayne State University, Detroit, MI; Children's Hospital of Michigan, Detroit, MI
| | - Benjamin S Bassin
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI
| | | | - Michaelina Bolton
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI; Hurley Medical Center, Flint, MI
| | - Blaine J Dennis
- Beaumont Health System, Royal Oak, MI; Oakland University William Beaumont School of Medicine, Rochester, MI; Beaumont Hospital, Royal Oak and Troy, MI
| | - Jason J Ham
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI; Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Seth S Krupp
- Department of Emergency Medicine, Wayne State University, Detroit, MI; Henry Ford Health System, Detroit, MI
| | - Kelly A Levasseur
- Oakland University William Beaumont School of Medicine, Rochester, MI; Beaumont Health System, Royal Oak, MI; Beaumont Hospital, Royal Oak and Troy, MI; Beaumont Children's Hospital, Royal Oak, MI
| | - Michelle L Macy
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI; Child Health Evaluation and Research (CHEAR) Center, University of Michigan Medical School, Ann Arbor, MI; Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Brian J O'Neil
- Department of Emergency Medicine, Wayne State University, Detroit, MI
| | - James M Pribble
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI
| | - Robert L Sherwin
- Department of Emergency Medicine, Wayne State University, Detroit, MI
| | - Nicole S Sroufe
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI; Department of Pediatrics, University of Michigan, Ann Arbor, MI
| | - Bradley J Uren
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI
| | - Michele M Nypaver
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI; Department of Pediatrics, University of Michigan, Ann Arbor, MI
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Simon E, Miake-Lye IM, Smith SW, Swartz JL, Horwitz LI, Makarov DV, Gyftopoulos S. An Evaluation of Guideline-Discordant Ordering Behavior for CT Pulmonary Angiography in the Emergency Department. J Am Coll Radiol 2019; 16:1064-1072. [PMID: 31047834 DOI: 10.1016/j.jacr.2018.12.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Revised: 12/04/2018] [Accepted: 12/14/2018] [Indexed: 01/23/2023]
Abstract
PURPOSE The aim of this study was to determine rates of and possible reasons for guideline-discordant ordering of CT pulmonary angiography for the evaluation of suspected pulmonary embolism (PE) in the emergency department. METHODS A retrospective review was performed of 212 consecutive encounters (January 6, 2016, to February 25, 2016) with 208 unique patients in the emergency department that resulted in CT pulmonary angiography orders. For each encounter, the revised Geneva score and two versions of the Wells criteria were calculated. Each encounter was then classified using a two-tiered risk stratification method (PE unlikely versus PE likely). Finally, the rate of and possible explanations for guideline-discordant ordering were assessed via in-depth chart review. RESULTS The frequency of guideline-discordant studies ranged from 53 (25%) to 79 (37%), depending on the scoring system used; 46 (22%) of which were guideline discordant under all three scoring systems. Of these, 18 (39%) had at least one patient-specific factor associated with increased risk for PE but not included in the risk stratification scores (eg, travel, thrombophilia). CONCLUSIONS Many of the guideline-discordant orders were placed for patients who presented with evidence-based risk factors for PE that are not included in the risk stratification scores. Therefore, guideline-discordant ordering may indicate that in the presence of these factors, the assessment of risk made by current scoring systems may not align with clinical suspicion.
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Affiliation(s)
- Emma Simon
- Department of Population Health, NYU School of Medicine, New York, New York; Center for Healthcare Innovation and Delivery Science, NYU School of Medicine, New York, New York.
| | - Isomi M Miake-Lye
- Center for Healthcare Innovation and Delivery Science, NYU School of Medicine, New York, New York; VA Greater Los Angeles Healthcare System, Los Angeles, California
| | - Silas W Smith
- Ronald O. Perelman Department of Emergency Medicine, NYU School of Medicine, New York, New York; Institute for Innovations in Medical Education, NYU School of Medicine, New York, New York
| | - Jordan L Swartz
- Ronald O. Perelman Department of Emergency Medicine, NYU School of Medicine, New York, New York
| | - Leora I Horwitz
- Department of Population Health, NYU School of Medicine, New York, New York; Center for Healthcare Innovation and Delivery Science, NYU School of Medicine, New York, New York; Department of Medicine, NYU School of Medicine, New York, New York
| | - Danil V Makarov
- Department of Population Health, NYU School of Medicine, New York, New York; Department of Urology, NYU School of Medicine, New York, New York; VA New York Harbor Healthcare System, NYU School of Medicine, New York, New York
| | - Soterios Gyftopoulos
- Department of Radiology, NYU School of Medicine, New York, New York; Department of Orthopedic Surgery, NYU School of Medicine, New York, New York
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Increasing rate of pulmonary embolism diagnosed in hospitalized children in the United States from 2001 to 2014. Blood Adv 2019; 2:1403-1408. [PMID: 29907635 DOI: 10.1182/bloodadvances.2017013292] [Citation(s) in RCA: 62] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2017] [Accepted: 04/12/2018] [Indexed: 12/23/2022] Open
Abstract
Although rare in children, pulmonary embolism (PE) can cause significant morbidity and mortality. Overall rates of venous thromboembolism (VTE) are increasing in hospitalized children. By using the Pediatric Health Information System database, we evaluated incidence, treatment, and outcome of PE in children younger than age 18 years from 2001 to 2014. Demographic characteristics for those admitted with VTE alone and those admitted with PE were compared. Rates of PE by year were compared with the number of hospital and VTE admissions. Trends in medication use were analyzed. Over the period of the study, patients with PE made up 15.8% of VTE discharges. The overall rate of PE increased 200% (P < .001). Compared with all other age groups, adolescents (age 13-18 years) had the highest prevalence (55%; P < .001), the rate of which increased from 9.8 to 24.7 per 10 000 hospital discharges (152%; P < .001), and from 17.5 to 34.1 per 100 VTE discharges (95%; P < .001). Individuals with PE had a higher mortality (8.3% vs 6%; P < .001) and were less likely to have a complex chronic condition (58% vs 65%; P < .001) than those with VTE alone. However, PE mortality rates decreased over the time period studied. African American and Hispanic patients were more likely to experience recurrent PE than white patients (12% and 10.7% vs 8%; P = .002). During the study period, the use of unfractionated heparin decreased (P < .001), and the use of low molecular weight heparin increased (P < .001). Further research is required to determine what factors contribute to the higher rate of PE in adolescents and influence recurrence in African American and Hispanic patients.
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Prentice D, Wipke-Tevis DD. Diagnosis of pulmonary embolism: Following the evidence from suspicion to certainty. JOURNAL OF VASCULAR NURSING 2019; 37:28-42. [PMID: 30954195 DOI: 10.1016/j.jvn.2018.10.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Revised: 09/23/2018] [Accepted: 10/02/2018] [Indexed: 12/16/2022]
Abstract
Accurate, timely and cost-effective identification of pulmonary embolism remains a diagnostic challenge. This article reviews the pulmonary embolism diagnostic process with a focus on the best practice advice from the American College of Physicians. Benefits and risks of each diagnostic step are discussed. Emerging diagnostic tools, not included in the algorithm, are briefly reviewed.
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Affiliation(s)
- Donna Prentice
- Clinical Nurse Specialist, Barnes-Jewish Hospital, St. Louis, MO; PhD Candidate, Sinclair School of Nursing, University of Missouri, Columbia, MO.
| | - Deidre D Wipke-Tevis
- Associate Professor and PhD Program Director, Sinclair School of Nursing, University of Missouri, Columbia, MO
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Khan S, Richardson S, Liu A, Mechery V, McCullagh L, Schachter A, Pardo S, McGinn T. Improving Provider Adoption With Adaptive Clinical Decision Support Surveillance: An Observational Study. JMIR Hum Factors 2019; 6:e10245. [PMID: 30785410 PMCID: PMC6401673 DOI: 10.2196/10245] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Revised: 10/28/2018] [Accepted: 11/25/2018] [Indexed: 01/12/2023] Open
Abstract
Background Successful clinical decision support (CDS) tools can help use evidence-based medicine to effectively improve patient outcomes. However, the impact of these tools has been limited by low provider adoption due to overtriggering, leading to alert fatigue. We developed a tracking mechanism for monitoring trigger (percent of total visits for which the tool triggers) and adoption (percent of completed tools) rates of a complex CDS tool based on the Wells criteria for pulmonary embolism (PE). Objective We aimed to monitor and evaluate the adoption and trigger rates of the tool and assess whether ongoing tool modifications would improve adoption rates. Methods As part of a larger clinical trial, a CDS tool was developed using the Wells criteria to calculate pretest probability for PE at 2 tertiary centers’ emergency departments (EDs). The tool had multiple triggers: any order for D-dimer, computed tomography (CT) of the chest with intravenous contrast, CT pulmonary angiography (CTPA), ventilation-perfusion scan, or lower extremity Doppler ultrasound. A tracking dashboard was developed using Tableau to monitor real-time trigger and adoption rates. Based on initial low provider adoption rates of the tool, we conducted small focus groups with key ED providers to elicit barriers to tool use. We identified overtriggering of the tool for non-PE-related evaluations and inability to order CT testing for intermediate-risk patients. Thus, the tool was modified to allow CT testing for the intermediate-risk group and not to trigger for CT chest with intravenous contrast orders. A dialogue box, “Are you considering PE for this patient?” was added before the tool triggered to account for CTPAs ordered for aortic dissection evaluation. Results In the ED of tertiary center 1, 95,295 patients visited during the academic year. The tool triggered for an average of 509 patients per month (average trigger rate 2036/30,234, 6.73%) before the modifications, reducing to 423 patients per month (average trigger rate 1629/31,361, 5.22%). In the ED of tertiary center 2, 88,956 patients visited during the academic year, with the tool triggering for about 473 patients per month (average trigger rate 1892/29,706, 6.37%) before the modifications and for about 400 per month (average trigger rate 1534/30,006, 5.12%) afterward. The modifications resulted in a significant 4.5- and 3-fold increase in provider adoption rates in tertiary centers 1 and 2, respectively. The modifications increased the average monthly adoption rate from 23.20/360 (6.5%) tools to 81.60/280.20 (29.3%) tools and 46.60/318.80 (14.7%) tools to 111.20/263.40 (42.6%) tools in centers 1 and 2, respectively. Conclusions Close postimplementation monitoring of CDS tools may help improve provider adoption. Adaptive modifications based on user feedback may increase targeted CDS with lower trigger rates, reducing alert fatigue and increasing provider adoption. Iterative improvements and a postimplementation monitoring dashboard can significantly improve adoption rates.
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Affiliation(s)
- Sundas Khan
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, United States
| | - Safiya Richardson
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, United States
| | - Andrew Liu
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, United States
| | - Vinodh Mechery
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, United States
| | - Lauren McCullagh
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, United States
| | - Andy Schachter
- Office of Chief Informatics Officer, Northwell Health, Manhasset, NY, United States
| | - Salvatore Pardo
- Emergency Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, United States
| | - Thomas McGinn
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, United States
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Fahimi J, Kanzaria HK, Mongan J, Kahn KL, Wang RC. Potential Effect of the Protecting Access to Medicare Act on Use of Advanced Diagnostic Imaging in the Emergency Department: An Analysis of the National Hospital Ambulatory Care Survey. Radiology 2019; 291:188-193. [PMID: 30694161 DOI: 10.1148/radiol.2019181650] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Background Clinical decision support is increasingly used to enhance clinicians' exposure to established evidence and patient information during an episode of patient care. Pending legislation specifies clinical decision support before performing advanced imaging at emergency department (ED) visits. Purpose To estimate the volume of advanced imaging tests (CT and MRI) that would require use of clinical decision support to achieve Protecting Access to Medicare Act (PAMA) compliance in the ED. Materials and Methods A retrospective, cross-sectional analysis of ED visits was conducted by using data from the 2012-2015 National Hospital Ambulatory Care Survey. PAMA-related visits were identified by selecting the patient reasons for visit (RFVs) related to the eight clinical conditions. Results Among the adult ED visits, 26.7% (20 506 of 77 299, representing 113 000 000 visits across 4 years, or 28 000 000 visits annually) patients presented with a RFV consistent with a PAMA priority clinical area (PCA). Among visits in which a patient described an RFV code consistent with a PAMA PCA, up to 22.9% (4681 of 20 506; 95% confidence interval: 21.8%, 24.1%) patients underwent advanced imaging, translating to approximately 6 000 000 visits annually. Conclusion Protecting Access to Medicare Act legislation targets eight priority clinical areas, estimated to be prevalent among one in four adult emergency department visits. CT and/or MRI studies are performed during up to 23% of these visits. Depending on the particular clinical decision support systems selected within a health system, and how they are implemented, the potential volume of studies in which clinicians must interact with clinical decision support system may either exceed or fall short of these estimates. © RSNA, 2019 Online supplemental material is available for this article. See also the editorial by Forman in this issue.
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Affiliation(s)
- Jahan Fahimi
- From the Department of Emergency Medicine (J.F., H.K.K., R.C.W.), Center for Healthcare Value (J.F.), Philip R. Lee Institute for Health Policy Studies (H.K.K.), and Department of Radiology and Biomedical Imaging (J.M.), University of California, San Francisco, 505 Parnassus Ave, L126, San Francisco, CA 94143-0209; Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, Calif (K.L.K.); and RAND Corporation, Santa Monica, Calif (K.L.K.)
| | - Hemal K Kanzaria
- From the Department of Emergency Medicine (J.F., H.K.K., R.C.W.), Center for Healthcare Value (J.F.), Philip R. Lee Institute for Health Policy Studies (H.K.K.), and Department of Radiology and Biomedical Imaging (J.M.), University of California, San Francisco, 505 Parnassus Ave, L126, San Francisco, CA 94143-0209; Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, Calif (K.L.K.); and RAND Corporation, Santa Monica, Calif (K.L.K.)
| | - John Mongan
- From the Department of Emergency Medicine (J.F., H.K.K., R.C.W.), Center for Healthcare Value (J.F.), Philip R. Lee Institute for Health Policy Studies (H.K.K.), and Department of Radiology and Biomedical Imaging (J.M.), University of California, San Francisco, 505 Parnassus Ave, L126, San Francisco, CA 94143-0209; Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, Calif (K.L.K.); and RAND Corporation, Santa Monica, Calif (K.L.K.)
| | - Katherine L Kahn
- From the Department of Emergency Medicine (J.F., H.K.K., R.C.W.), Center for Healthcare Value (J.F.), Philip R. Lee Institute for Health Policy Studies (H.K.K.), and Department of Radiology and Biomedical Imaging (J.M.), University of California, San Francisco, 505 Parnassus Ave, L126, San Francisco, CA 94143-0209; Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, Calif (K.L.K.); and RAND Corporation, Santa Monica, Calif (K.L.K.)
| | - Ralph Charles Wang
- From the Department of Emergency Medicine (J.F., H.K.K., R.C.W.), Center for Healthcare Value (J.F.), Philip R. Lee Institute for Health Policy Studies (H.K.K.), and Department of Radiology and Biomedical Imaging (J.M.), University of California, San Francisco, 505 Parnassus Ave, L126, San Francisco, CA 94143-0209; Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, Calif (K.L.K.); and RAND Corporation, Santa Monica, Calif (K.L.K.)
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Richardson S, Solomon P, O'Connell A, Khan S, Gong J, Makhnevich A, Qiu G, Zhang M, McGinn T. A Computerized Method for Measuring Computed Tomography Pulmonary Angiography Yield in the Emergency Department: Validation Study. JMIR Med Inform 2018; 6:e44. [PMID: 30361200 PMCID: PMC6231863 DOI: 10.2196/medinform.9957] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Revised: 05/16/2018] [Accepted: 07/06/2018] [Indexed: 11/13/2022] Open
Abstract
Background Use of computed tomography pulmonary angiography (CTPA) in the assessment of pulmonary embolism (PE) has markedly increased over the past two decades. While this technology has improved the accuracy of radiological testing for PE, CTPA also carries the risk of substantial iatrogenic harm. Each CTPA carries a 14% risk of contrast-induced nephropathy and a lifetime malignancy risk that can be as high as 2.76%. The appropriate use of CTPA can be estimated by monitoring the CTPA yield, the percentage of tests positive for PE. This is the first study to propose and validate a computerized method for measuring the CTPA yield in the emergency department (ED). Objective The objective of our study was to assess the validity of a novel computerized method of calculating the CTPA yield in the ED. Methods The electronic health record databases at two tertiary care academic hospitals were queried for CTPA orders completed in the ED over 1-month periods. These visits were linked with an inpatient admission with a discharge diagnosis of PE based on the International Classification of Diseases codes. The computerized the CTPA yield was calculated as the number of CTPA orders with an associated inpatient discharge diagnosis of PE divided by the total number of orders for completed CTPA. This computerized method was then validated by 2 independent reviewers performing a manual chart review, which included reading the free-text radiology reports for each CTPA. Results A total of 349 CTPA orders were completed during the 1-month periods at the two institutions. Of them, acute PE was diagnosed on CTPA in 28 studies, with a CTPA yield of 7.7%. The computerized method correctly identified 27 of 28 scans positive for PE. The one discordant scan was tied to a patient who was discharged directly from the ED and, as a result, never received an inpatient discharge diagnosis. Conclusions This is the first successful validation study of a computerized method for calculating the CTPA yield in the ED. This method for data extraction allows for an accurate determination of the CTPA yield and is more efficient than manual chart review. With this ability, health care systems can monitor the appropriate use of CTPA and the effect of interventions to reduce overuse and decrease preventable iatrogenic harm.
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Affiliation(s)
- Safiya Richardson
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, United States
| | - Philip Solomon
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, United States
| | - Alexander O'Connell
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, United States
| | - Sundas Khan
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, United States
| | - Jonathan Gong
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, United States
| | - Alex Makhnevich
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, United States
| | - Guang Qiu
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, United States
| | - Meng Zhang
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, United States
| | - Thomas McGinn
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, United States
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Kanis J, Hall CL, Pike J, Kline JA. Diagnostic accuracy of the D-dimer in children. Arch Dis Child 2018; 103:832-834. [PMID: 29117965 DOI: 10.1136/archdischild-2017-313315] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Revised: 09/26/2017] [Accepted: 09/29/2017] [Indexed: 11/04/2022]
Abstract
BACKGROUND We sought to measure the diagnostic accuracy of D-dimer in children with suspected pulmonary embolism (PE). METHODS We queried our electronic medical record for quantitative D-dimer values obtained in all children ages 5-17 over 10 years in our 10-hospital system. Patients who had a D-dimer obtained in the evaluation of PE underwent supervised chart review to extract baseline demographics (age, sex, ethnicity), medical history, laboratory data and imaging results. PE was confirmed by imaging positive for deep vein thrombosis (DVT) or PE and excluded by imaging or no DVT or PE diagnosis within 90 days. RESULTS Over a 10-year period, we identified 13 792 orders for D-dimer testing in 2554 unique patients. Chart review indicated that 526 (20.6%) unique patients had D-dimer testing performed in the evaluation of PE (Cohen's kappa=0.95, 95% CI 0.85 to 1.0). Most D-dimers (465/526, 88%) were ordered in children aged >12 years. Of these 526 children, 34 (6.4%, 95% CI) had a criterion standard positive for new or recurrent PE. The mean D-dimer value was 2104±1394 ng/mL in the 34/34 PE+ children and 586±962 ng/mL in PE- children with a sensitivity of 34/34 (100%, 89% to 100%) and a specificity of 290/492 (58%, 54% to 63%). The area under the receiver operating characteristic curve was 0.90 ((0.9)87-0.94). CONCLUSIONS D-dimer is currently ordered in children for suspected PE in the emergency care setting, mostly in teenagers. The observed lower limit 95% CIs of 89% and 54% for diagnostic sensitivity and the specificity, respectively, suggest if used in patients with low-clinical probability, a normal D-dimer can safely exclude PE in children.
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Affiliation(s)
- Jessica Kanis
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Cassandra L Hall
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Jonathan Pike
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Jeffrey A Kline
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
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Comparison of the age-adjusted and clinical probability-adjusted D-dimer to exclude pulmonary embolism in the ED. Am J Emerg Med 2018; 37:845-850. [PMID: 30077494 DOI: 10.1016/j.ajem.2018.07.053] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Revised: 07/23/2018] [Accepted: 07/29/2018] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Diagnosing pulmonary embolism (PE) in the emergency department (ED) can be challenging because its signs and symptoms are non-specific. OBJECTIVE We compared the efficacy and safety of using age-adjusted D-dimer interpretation, clinical probability-adjusted D-dimer interpretation and standard D-dimer approach to exclude PE in ED patients. DESIGN/METHODS We performed a health records review at two emergency departments over a two-year period. We reviewed all cases where patients had a D-dimer ordered to test for PE or underwent CT or VQ scanning for PE. PE was considered to be present during the emergency department visit if PE was diagnosed on CT or VQ (subsegmental level or above), or if the patient was subsequently found to have PE or deep vein thrombosis during the next 30 days. We applied the three D-dimer approaches to the low and moderate probability patients. The primary outcome was exclusion of PE with each rule. Secondary objective was to estimate the negative predictive value (NPV) for each rule. RESULTS 1163 emergency patients were tested for PE and 1075 patients were eligible for inclusion in our analysis. PE was excluded in 70.4% (95% CI 67.6-73.0%), 80.3% (95% CI 77.9-82.6%) and 68.9%; (95% CI 65.7-71.3%) with the age-adjusted, clinical probability-adjusted and standard D-dimer approach. The NPVs were 99.7% (95% CI 99.0-99.9%), 99.1% (95% CI 98.3-99.5%) and 100% (95% CI 99.4-100.0%) respectively. CONCLUSION The clinical probability-adjusted rule appears to exclude PE in a greater proportion of patients, with a very small reduction in the negative predictive value.
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Soo Hoo GW, Tsai E, Vazirani S, Li Z, Barack BM, Wu CC. Long-Term Experience With a Mandatory Clinical Decision Rule and Mandatory d-Dimer in the Evaluation of Suspected Pulmonary Embolism. J Am Coll Radiol 2018; 15:1673-1680. [PMID: 29907418 DOI: 10.1016/j.jacr.2018.04.031] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2018] [Revised: 04/13/2018] [Accepted: 04/30/2018] [Indexed: 02/03/2023]
Abstract
PURPOSE This study evaluated the long-term effectiveness of mandatory assignment of both a clinical decision rule (CDR) and highly sensitive d-dimer in the evaluation of patients with suspected pulmonary embolism (PE). MATERIALS AND METHODS Institutional guidelines with a CDR and highly sensitive d-dimer were embedded in an order entry menu with mandatory assignment of key components before ordering a CT pulmonary angiogram (CTPA). Data were retrospectively extracted from the electronic health record. RESULTS This was a retrospective review of 1,003 CTPA studies (905 patients, 845 male and 60 female patients, age 63.7 ± 13.5 years). CTPAs were positive for PE in 170 studies (17%), representing an average yield of 15% (year [average]; 2007 [15%], 2008 [18%], 2009 [15%], 2010 [15%], 2011 [17%], 2012 [15%], 2013 [23%]). The increased yield represented efforts of mandatory order entry assignments, educational sessions, and clinical champions. Different d-dimer thresholds with or without age adjustments in combination with the CDR identified about 10% of patients who may have been managed without CTPA. CONCLUSION Mandatory assignment of a CDR and highly sensitive d-dimer clinical decision pathway can be successfully incorporated into an order entry menu and produce a sustained increase in CTPA yield of patients with suspected PE.
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Affiliation(s)
- Guy W Soo Hoo
- Pulmonary and Critical Care, Internal Medicine, and Radiology, West Los Angeles VA Healthcare Center, Los Angeles, California.
| | - Emily Tsai
- Department of Radiology, Stanford University School of Medicine, Stanford, California
| | - Sondra Vazirani
- Pulmonary and Critical Care, Internal Medicine, and Radiology, West Los Angeles VA Healthcare Center, Los Angeles, California
| | - Zhaoping Li
- Pulmonary and Critical Care, Internal Medicine, and Radiology, West Los Angeles VA Healthcare Center, Los Angeles, California
| | - Bruce M Barack
- Pulmonary and Critical Care, Internal Medicine, and Radiology, West Los Angeles VA Healthcare Center, Los Angeles, California
| | - Carol C Wu
- Department of Diagnostic Radiology, University of Texas MD Anderson Cancer Center, Houston, Texas
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Affiliation(s)
- Harvey S. Hecht
- From the Icahn School of Medicine at Mount Sinai, New York (H.S.H., J.N.); and Department of Medicine and Radiology, University of British Columbia, Vancouver, Canada (J.L.)
| | - Jagat Narula
- From the Icahn School of Medicine at Mount Sinai, New York (H.S.H., J.N.); and Department of Medicine and Radiology, University of British Columbia, Vancouver, Canada (J.L.)
| | - Jonathon Leipsic
- From the Icahn School of Medicine at Mount Sinai, New York (H.S.H., J.N.); and Department of Medicine and Radiology, University of British Columbia, Vancouver, Canada (J.L.)
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Deblois S, Chartrand-Lefebvre C, Toporowicz K, Chen Z, Lepanto L. Interventions to Reduce the Overuse of Imaging for Pulmonary Embolism: A Systematic Review. J Hosp Med 2018; 13:52-61. [PMID: 29309438 DOI: 10.12788/jhm.2902] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Imaging use in the diagnostic workup of pulmonary embolism (PE) has increased markedly in the last 2 decades. Low PE prevalence and diagnostic yields suggest a significant problem of overuse. PURPOSE The purpose of this systematic review is to summarize the evidence associated with the interventions aimed at reducing the overuse of imaging in the diagnostic workup of PE in the emergency department and hospital wards. DATA SOURCES PubMed, MEDLINE, Embase, and EBM Reviews from 1998 to March 28, 2017. STUDY SELECTION Experimental and observational studies were included. The types of interventions, their efficacy and safety, the impact on healthcare costs, the facilitators, and barriers to their implementation were assessed. DATA SYNTHESIS Seventeen studies were included assessing clinical decision support (CDS), educational interventions, performance and feedback reports (PFRs), and institutional policy. CDS impact was most comprehensively documented. It was associated with a reduction in imaging use, ranging from 8.3% to 25.4%, and an increase in diagnostic yield, ranging from 3.4% to 4.4%. The combined implementation of a CDS and PFR resulted in a modest but significant increase in the adherence to guidelines. Few studies appraised the safety of interventions. There was a lack of evidence concerning economic aspects, facilitators, and barriers. CONCLUSIONS A combined implementation of an electronic CDS and PFRs is more effective than purely educational or policy interventions, although evidence is limited. Future studies of high-methodological quality would strengthen the evidence concerning their efficacy, safety, facilitators, and barriers.
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Affiliation(s)
- Simon Deblois
- Health Technology Assessment Unit, Centre Hospitalier de l'Université de Montréal (CHUM), Montréal, Québec, Canada.
| | - Carl Chartrand-Lefebvre
- Radiology Department, Centre Hospitalier de l'Université de Montréal (CHUM), Montréal, Québec, Canada
- Centre de Recherche du CHUM, Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada
| | - Kevin Toporowicz
- Radiology Department, Centre Hospitalier de l'Université de Montréal (CHUM), Montréal, Québec, Canada
| | - Zhongyi Chen
- Radiology Department, Centre Hospitalier de l'Université de Montréal (CHUM), Montréal, Québec, Canada
| | - Luigi Lepanto
- Health Technology Assessment Unit, Centre Hospitalier de l'Université de Montréal (CHUM), Montréal, Québec, Canada
- Centre de Recherche du CHUM, Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada
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Buchanan I, Teeples T, Carlson M, Steenblik J, Bledsoe J, Madsen T. Pulmonary Embolism Testing Among Emergency Department Patients Who Are Pulmonary Embolism Rule-out Criteria Negative. Acad Emerg Med 2017; 24:1369-1376. [PMID: 28787100 DOI: 10.1111/acem.13270] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Revised: 07/25/2017] [Accepted: 07/29/2017] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Previous studies have demonstrated that rates of pulmonary embolism (PE) testing have increased without a concomitant decrease in PE-related mortality. The Pulmonary Embolism Rule-out Criteria (PERC) intend to reduce testing for PE in the emergency department (ED) by identifying low-risk patients ("PERC-negative") who do not require D-dimer, computed tomography pulmonary angiogram (CTPA), or ventilation/perfusion (VQ) scan for PE. This study assesses PE testing rates among PERC-negative patients presenting to an urban academic ED. METHODS We prospectively enrolled a convenience sample of ED patients with chest pain and/or shortness of breath presenting between June 2010 and December 2015. We recorded baseline variables at the time of ED presentation, information on testing performed in the ED, and the diagnosis of acute PE during the ED visit. We classified patients as PERC-positive or PERC-negative utilizing baseline variables and clinical characteristics. RESULTS Of the 3,024 study patients, 54.8% (95% confidence interval = 53%-56.5%) were female and the mean age was 51.7 (51.1-52.3) years. A total of 17.5% (16.2%-18.9%) of study patients were PERC-negative and 33.7% (32%-35.4%) of all patients underwent testing for PE. A total of 25.5% (22%-29.4%) of PERC-negative patients had PE testing compared to 35.4% (33.6%-37.3%) of PERC-positive patients (p < 0.001). A total of 7.2% (5.3%-9.7%) of PERC-negative patients had advanced imaging without a D-dimer compared to 19.2% (17.8%-20.8%) of PERC-positive patients (p < 0.001). In multivariate analysis, factors associated with PE testing in PERC-negative patients included age, white non-Hispanic race/ethnicity, pleuritic chest pain, and a complaint of both chest pain and shortness of breath. Two PERC-negative patients (0.4%) were diagnosed with an acute PE in the ED compared to 2.2% of PERC-positive patients (p = 0.008). The overall testing yield for PE was 1.6% (0.4%-9.2%) among PERC-negative patients versus 6.3% (4.9%-8.1%) among PERC-positive patients (p = 0.017). CONCLUSION In an academic ED, a significant proportion of PERC-negative patients underwent testing for PE, including CT or VQ scan without D-dimer risk stratification. Future areas of research may include evaluating factors that lead clinicians to pursue PE testing in PERC-negative patients and implementing clinical pathways to minimize practice variability among these patients.
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Affiliation(s)
- Ian Buchanan
- Division of Emergency Medicine; University of Utah School of Medicine; Salt Lake City UT
| | - Troy Teeples
- Division of Emergency Medicine; University of Utah School of Medicine; Salt Lake City UT
| | - Margaret Carlson
- Division of Emergency Medicine; University of Utah School of Medicine; Salt Lake City UT
| | - Jacob Steenblik
- Division of Emergency Medicine; University of Utah School of Medicine; Salt Lake City UT
| | - Joseph Bledsoe
- Emergency Department; Intermountain Medical Center; Murray UT
| | - Troy Madsen
- Division of Emergency Medicine; University of Utah School of Medicine; Salt Lake City UT
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Özsu SS, Durmuş ZG, Coşkuner MB, Bülbül Y, Öztuna F, Özlü T. Does the Incidence and Mortality of Pulmonary Thromboembolism Change Over the Years? Turk Thorac J 2017; 18:78-81. [PMID: 29404166 DOI: 10.5152/turkthoracj.2017.16050] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2017] [Accepted: 04/18/2017] [Indexed: 11/22/2022]
Abstract
OBJECTIVES In the last 20 years, with the use of computed tomography (CT) angiography, the number of patients diagnosed with pulmonary thromboembolism (PTE) has increased. At the same time, data show that pulmonary embolism mortality has also reduced in this duration. MATERIAL AND METHODS In this study, we analyzed records of patients with PTE (using ICD's) in the hospital automation system from 2001 to 2013. Data regarding age, sex, date of diagnosis, diagnosis of cancer, hemodynamic status, initial and maintenance treatment, hospital length of stay, and hospital mortality were recorded. Primary endpoints of the study were hospital length of stay and all-cause hospital mortality. RESULTS The total number of patients included in the study was 1185. The median age was 61 years in 2001 and 71 years in 2013. The number of patients who were diagnosed using CT increased from 10% to 92.8%. Between 2001 and 2013, the number of patients diagnosed with PTE increased, and of all patients with PTE, 13.7% was diagnosed in 2009. The hospital length of stay of 13 days declined to 9 days. The use of a vena cava filter in 2007 was 1.1% and that in 2013 was 4.6%. Mortality rate was 15%, however hospital mortality did not significantly differ over the years but varied between 9.4% and 18.8%. Increased use of thrombolytics in patients with massive PTE has been observed over the years. Massive PTE ratio in 2006 was 8.5% and thrombolytic use was 5.8%, however in 2013, these ratios were 2.6%, 6% respectively (p=0.017). CONCLUSION Finally, despite the increased number of patients diagnosed with PTE over the years, the mortality rate was not observed to have changed from 2001 to 2013.
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Affiliation(s)
- Savaş Sedat Özsu
- Department of Chest Diseases, Karadeniz Technical University School of Medicine, Trabzon, Turkey
| | - Zerrin Gürel Durmuş
- Department of Chest Diseases, Karadeniz Technical University School of Medicine, Trabzon, Turkey
| | - Mustafa Buğra Coşkuner
- Department of Chest Diseases, Karadeniz Technical University School of Medicine, Trabzon, Turkey
| | - Yılmaz Bülbül
- Department of Chest Diseases, Karadeniz Technical University School of Medicine, Trabzon, Turkey
| | - Funda Öztuna
- Department of Chest Diseases, Karadeniz Technical University School of Medicine, Trabzon, Turkey
| | - Tevfik Özlü
- Department of Chest Diseases, Karadeniz Technical University School of Medicine, Trabzon, Turkey
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Role of Clinical Decision Tools in the Diagnosis of Pulmonary Embolism. AJR Am J Roentgenol 2017; 208:W60-W70. [DOI: 10.2214/ajr.16.17206] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Dalen JE, Waterbrook AL. Why Are Nearly All CT Pulmonary Angiograms for Suspected Pulmonary Embolism Negative? Am J Med 2017; 130:247-248. [PMID: 27908793 DOI: 10.1016/j.amjmed.2016.03.043] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2016] [Accepted: 03/21/2016] [Indexed: 11/30/2022]
Affiliation(s)
- James E Dalen
- Dean Emeritus, University of Arizona College of Medicine, Tucson.
| | - Anna L Waterbrook
- Department of Emergency Medicine, University of Arizona College of Medicine, Tucson
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Swartz J, Koziatek C, Theobald J, Smith S, Iturrate E. Creation of a simple natural language processing tool to support an imaging utilization quality dashboard. Int J Med Inform 2017; 101:93-99. [PMID: 28347453 DOI: 10.1016/j.ijmedinf.2017.02.011] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Revised: 02/10/2017] [Accepted: 02/18/2017] [Indexed: 10/20/2022]
Abstract
BACKGROUND Testing for venous thromboembolism (VTE) is associated with cost and risk to patients (e.g. radiation). To assess the appropriateness of imaging utilization at the provider level, it is important to know that provider's diagnostic yield (percentage of tests positive for the diagnostic entity of interest). However, determining diagnostic yield typically requires either time-consuming, manual review of radiology reports or the use of complex and/or proprietary natural language processing software. OBJECTIVES The objectives of this study were twofold: 1) to develop and implement a simple, user-configurable, and open-source natural language processing tool to classify radiology reports with high accuracy and 2) to use the results of the tool to design a provider-specific VTE imaging dashboard, consisting of both utilization rate and diagnostic yield. METHODS Two physicians reviewed a training set of 400 lower extremity ultrasound (UTZ) and computed tomography pulmonary angiogram (CTPA) reports to understand the language used in VTE-positive and VTE-negative reports. The insights from this review informed the arguments to the five modifiable parameters of the NLP tool. A validation set of 2,000 studies was then independently classified by the reviewers and by the tool; the classifications were compared and the performance of the tool was calculated. RESULTS The tool was highly accurate in classifying the presence and absence of VTE for both the UTZ (sensitivity 95.7%; 95% CI 91.5-99.8, specificity 100%; 95% CI 100-100) and CTPA reports (sensitivity 97.1%; 95% CI 94.3-99.9, specificity 98.6%; 95% CI 97.8-99.4). The diagnostic yield was then calculated at the individual provider level and the imaging dashboard was created. CONCLUSIONS We have created a novel NLP tool designed for users without a background in computer programming, which has been used to classify venous thromboembolism reports with a high degree of accuracy. The tool is open-source and available for download at http://iturrate.com/simpleNLP. Results obtained using this tool can be applied to enhance quality by presenting information about utilization and yield to providers via an imaging dashboard.
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Affiliation(s)
- Jordan Swartz
- New York University School of Medicine, Ronald O. Perelman Department of Emergency Medicine, New York, NY, United States.
| | - Christian Koziatek
- New York University School of Medicine, Ronald O. Perelman Department of Emergency Medicine, New York, NY, United States
| | - Jason Theobald
- Department of Emergency Medicine, Mount Sinai West Hospital, Mount Sinai St Luke's Hospital, New York, NY, United States
| | - Silas Smith
- New York University School of Medicine, Ronald O. Perelman Department of Emergency Medicine, New York, NY, United States
| | - Eduardo Iturrate
- New York University School of Medicine, Department of Internal Medicine, New York, NY, United States
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Mountain D, Keijzers G, Chu K, Joseph A, Read C, Blecher G, Furyk J, Bharat C, Velusamy K, Munro A, Baker K, Kinnear F, Mukherjee A, Watkins G, Buntine P, Livesay G, Fatovich D. RESPECT-ED: Rates of Pulmonary Emboli (PE) and Sub-Segmental PE with Modern Computed Tomographic Pulmonary Angiograms in Emergency Departments: A Multi-Center Observational Study Finds Significant Yield Variation, Uncorrelated with Use or Small PE Rates. PLoS One 2016; 11:e0166483. [PMID: 27918576 PMCID: PMC5137866 DOI: 10.1371/journal.pone.0166483] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Accepted: 10/28/2016] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Overuse of CT Pulmonary Angiograms (CTPA) for diagnosing pulmonary embolism (PE), particularly in Emergency Departments (ED), is considered problematic. Marked variations in positive CTPA rates are reported, with American 4-10% yields driving most concerns. Higher resolution CTPA may increase sub-segmental PE (SSPE) diagnoses, which may be up to 40% false positive. Excessive use and false positives could increase harm vs. benefit. These issues have not been systematically examined outside America. AIMS To describe current yield variation and CTPA utilisation in Australasian ED, exploring potential factors correlated with variation. METHODS A retrospective multi-centre review of consecutive ED-ordered CTPA using standard radiology reports. ED CTPA report data were inputted onto preformatted data-sheets. The primary outcome was site level yield, analysed both intra-site and against a nominated 15.3% yield. Factors potentially associated with yield were assessed for correlation. RESULTS Fourteen radiology departments (15 ED) provided 7077 CTPA data (94% ≥64-slice CT); PE were reported in 1028 (yield 14.6% (95%CI 13.8-15.4%; range 9.3-25.3%; site variation p <0.0001) with four sites significantly below and one above the 15.3% target. Admissions, CTPA usage, PE diagnosis rates and size of PE were uncorrelated with yield. Large PE (≥lobar) were 55% (CI: 52.1-58.2%) and SSPE 8.8% (CI: 7.1-10.5%) of positive scans. CTPA usage (0.2-1.5% adult attendances) was correlated (p<0.006) with PE diagnosis but not SSPE: large PE proportions. DISCUSSION/ CONCLUSIONS We found significant intra-site CTPA yield variation within Australasia. Yield was not clearly correlated with CTPA usage or increased small PE rates. Both SSPE and large PE rates were similar to higher yield historical cohorts. CTPA use was considerably below USA 2.5-3% rates. Higher CTPA utilisation was positively correlated with PE diagnoses, but without evidence of increased proportions of small PE. This suggests that increased diagnoses seem to be of clinically relevant sized PE.
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Affiliation(s)
- David Mountain
- Discipline of Emergency Medicine, School of Primary, Aboriginal and Rural Health Care, University of Western Australia, Perth, Australia
- Emergency Department, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Gerben Keijzers
- Emergency Medicine Department, Gold Coast University Hospital, Southport, Queensland, Australia
| | - Kevin Chu
- Department of Emergency Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia
- School of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Anthony Joseph
- Emergency Medicine, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Catherine Read
- Pleural Medicine Unit, Institute for Respiratory Health, Perth, Western Australia, Australia Centre for Respiratory Health, School of Medicine & Pharmacology, University of Western Australia, Perth, Western Australia, Australia
- Respiratory Medicine Unit (Research, Pleural Diseases) Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Gabriel Blecher
- Emergency Medicine, Monash Health, Melbourne, Victoria, Australia
- Department of Medicine, Monash University, Melbourne, Victoria, Australia
| | - Jeremy Furyk
- Emergency Department, The Townsville Hospital, Townsville, Queensland, Australia
| | - Chrianna Bharat
- Statistical Support, Department of Research, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
- Centre for Applied Statistics, University of Western Australia, Perth, Western Australia, Australia
| | - Karthik Velusamy
- Emergency Department, The Townsville Hospital, Townsville, Queensland, Australia
| | - Andrew Munro
- Emergency Department, Nelson Hospital, Nelson, New Zealand
| | - Kylie Baker
- Emergency Medicine, Ipswich Hospital, Ipswich, Queensland, Australia
| | - Frances Kinnear
- Emergency Medicine, The Prince Charles Hospital, Brisbane, Queensland, Australia
| | - Ahses Mukherjee
- Emergency Medicine, Armadale General Hospital, Perth, Western Australia, Australia
| | - Gina Watkins
- Emergency Medicine, Sutherland Hospital and Community Health Centres, Caringbah, Australia
| | - Paul Buntine
- Emergency Department, Box Hill Hospital, Melbourne, Victoria, Australia
| | - Georgia Livesay
- Emergency Medicine Research, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Daniel Fatovich
- Centre for Clinical Research in Emergency Medicine, Harry Perkins Institute of Medical Research, University of Western Australia, Perth, Australia
- Emergency Department, Royal Perth Hospital, Perth, Australia
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Anemia is not a risk factor for developing pulmonary embolism. Am J Emerg Med 2016; 35:146-149. [PMID: 27836322 DOI: 10.1016/j.ajem.2016.09.068] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2016] [Revised: 09/21/2016] [Accepted: 09/29/2016] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE Our aim was to validate the previously published claim of a positive relationship between low blood hemoglobin level (anemia) and pulmonary embolism (PE). METHODS This was a retrospective study of patients undergoing cross-sectional imaging to evaluate for PE at an academic medical center. Patients were identified using billing records for charges attributed to either magnetic resonance angiography or computed tomography angiography of the chest from 2008 to 2013. The main outcome measure was mean hemoglobin levels among those with and without PE. Our reference standard for PE status included index imaging results and a 6-month clinical follow-up for the presence of interval venous thromboembolism, conducted via review of the electronic medical record. Secondarily, we performed a subgroup analysis of only those patients who were seen in the emergency department. Finally, we again compared mean hemoglobin levels when limiting our control population to an age- and sex-matched cohort of the included cases. RESULTS There were 1294 potentially eligible patients identified, of whom 121 were excluded. Of the remaining 1173 patients, 921 had hemoglobin levels analyzed within 24 hours of their index scan and thus were included in the main analysis. Of those 921 patients, 107 (11.6%; 107/921) were positive for PE. We found no significant difference in mean hemoglobin level between those with and without PE regardless of the control group used (12.4 ± 2.1 g/dL and 12.3 ± 2.0 g/dL [P = .85], respectively). CONCLUSIONS Our data demonstrated no relationship between anemia and PE.
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