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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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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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