Improving appropriate use of pulmonary computed tomography angiography by increasing the serum D-dimer threshold and assessing clinical probability

Interventions to reduce low-value imaging - a systematic review of interventions and outcomes

BACKGROUND

It is estimated that 20-50% of all radiological examinations are of low value. Many attempts have been made to reduce the use of low-value imaging. However, the comparative effectiveness of interventions to reduce low-value imaging is unclear. Thus, the objective of this systematic review was to provide an overview and evaluate the outcomes of interventions aimed at reducing low-value imaging.

METHODS

An electronic database search was completed in Medline - Ovid, Embase-Ovid, Scopus, and Cochrane Library for citations between 2010 and 2020. The search was built from medical subject headings for Diagnostic imaging/Radiology, Health service misuse or medical overuse, and Health planning. Keywords were used for the concept of reduction and avoidance. Reference lists of included articles were also hand-searched for relevant citations. Only articles written in English, German, Danish, Norwegian, Dutch, and Swedish were included. The Mixed Methods Appraisal Tool was used to appraise the quality of the included articles. A narrative synthesis of the final included articles was completed.

RESULTS

The search identified 15,659 records. After abstract and full-text screening, 95 studies of varying quality were included in the final analysis, containing 45 studies found through hand-searching techniques. Both controlled and uncontrolled before-and-after studies, time series, chart reviews, and cohort studies were included. Most interventions were aimed at referring physicians. Clinical practice guidelines (n = 28) and education (n = 28) were most commonly evaluated interventions, either alone or in combination with other components. Multi-component interventions were often more effective than single-component interventions showing a reduction in the use of low-value imaging in 94 and 74% of the studies, respectively. The most addressed types of imaging were musculoskeletal (n = 26), neurological (n = 23) and vascular (n = 16) imaging. Seventy-seven studies reported reduced low-value imaging, while 3 studies reported an increase.

CONCLUSIONS

Multi-component interventions that include education were often more effective than single-component interventions. The contextual and cultural factors in the health care systems seem to be vital for successful reduction of low-value imaging. Further research should focus on assessing the impact of the context in interventions reducing low-value imaging and how interventions can be adapted to different contexts.

A proof of concept for epidemiological research using structured reporting with pulmonary embolism as a use case

OBJECTIVE

This paper studies the possibilities of an integrated IT-based workflow for epidemiological research in pulmonary embolism (PE) using freely available tools and structured reporting (SR).

METHODS

We included a total of 521 consecutive cases which had been referred to the radiology department for CT pulmonary angiography with suspected PE. Free-text reports were transformed into structured reports using a freely available IHE Management of Radiology Report Templates-compliant reporting platform. D-dimer values were retrieved from the hospitals laboratory results system. All information was stored in the platform's database and visualized using freely available tools. For further analysis, we directly accessed the platform's database with an advanced analytics tool (RapidMiner).

RESULTS

Results: We were able to develop an integrated workflow for epidemiological statistics from reports obtained in clinical routine. The report data allowed for automated calculation of epidemiological parameters. Prevalence of PE was 27.6%. The mean age in patients with and without PE did not differ (62.8 years and 62.0 years, respectively, p = 0.987). As expected, there was a significant difference in mean D-dimer values (10.13 and 3.12 mg l-1 fibrinogen equivalent units, respectively, p < 0.001).

CONCLUSION

SR can make data obtained from clinical routine more accessible. Designing practical workflows is feasible using freely available tools and allows for the calculation of epidemiological statistics on a near realtime basis. Therefore, radiologists should push for the implementation of SR in clinical routine. Summary sentence: Implementing practical workflows that allow for the calculation of epidemiological statistics using SR and freely available tools is easily feasible. Advances in knowledge: Theoretical benefits of SR have long been discussed, but practical implementation demonstrating those benefits has been lacking. Here, we present a first experience providing proof that SR will make data from clinical routine more accessible.

Interventions to Reduce the Overuse of Imaging for Pulmonary Embolism: A Systematic Review

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.

D-dimer Interval Likelihood Ratios for Pulmonary Embolism

OBJECTIVE

The objective was to estimate D-dimer interval likelihood ratios (iLRs) for diagnosing pulmonary embolism (PE).

METHODS

The authors used pooled patient-level data from five PE diagnostic management studies to estimate iLRs for the eight D-dimer intervals with boundaries 250, 500, 750, 1,000, 1,500, 2,500, and 5,000 ng/mL. Logistic regression was used to fit the data so that an interval increase corresponds to increasing the likelihood ratio by a constant factor.

RESULTS

The iLR for the D-dimer interval 1,000-1,499 ng/mL was essentially 1.0 (0.98 with 95% confidence interval [CI] = 0.82-1.18). In the logistic regression model, the constant between-interval factor was 2.0 (95% CI = 1.9-2.1). Using these iLR estimates, if the pre-D-dimer probability of PE is 15%, only a D-dimer less than 500 ng/mL will result in a posttest probability below 3%; if the pretest probability is 5%, the threshold for a "negative" D-dimer is 1,000 ng/mL.

CONCLUSIONS

A decision strategy based on these approximate iLRs agrees with several published strategies.