Age and sex-dependent trends in pulmonary embolism testing and derivation of a clinical decision rule for young patients

Mongan, John; Kline, Jeffrey A.; Smith‐Bindman, Rebecca

doi:10.1136/emermed-2014-204531

Cited by 20 publications

(36 citation statements)

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“…[1–4]However it is important to note that USA sites often report higher CTPA utilisation rates (20–35 per thousand adult ED attendances) than we describe here (2-15/1000). [8,23,35] It is possible there is a threshold utilisation rate beyond which yield drops dramatically without additional significant diagnoses, therefore providing minimal patient benefit, but significant increased harms.…”

Section: Discussionmentioning

confidence: 99%

“…[8,23,35] Variations in CTPA utilisation showed no association with yield, or with size of PE, but were strongly positively correlated with increased rates of PE per 1000 adult attendances (Fig 2). This, alongside the stable small and large PE rates (compared with historical data), suggests that additional PE’s diagnosed with increased CTPA use in our region would seem to be clinically important.…”

Section: Discussionmentioning

confidence: 99%

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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

et al. 2016

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IntroductionOveruse 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.AimsTo describe current yield variation and CTPA utilisation in Australasian ED, exploring potential factors correlated with variation.MethodsA 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.ResultsFourteen 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/ ConclusionsWe 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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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

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

et al. 2016

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“…Patients were grouped together into three groups based on age 15 16 : under 18 years old, 18–35 and over 35 years of age. Highest CT positivity was found in patients under 18 (16.0%, 4/25), followed by the 18–35 group (11.7%, 36/309) and patients over 35 (10.8%, 256/2379).…”

Section: Resultsmentioning

confidence: 99%

“…CTPA positivity rate was also determined for different age (under 18, 18–35, >35) and BMI groups (under 25, 25–40, >40). Decision to stratify the age groups was done to better study different physiological groups and categorisation based on prior studies (paediatric <18 years,15 young adults 18–35 years,16 and middle-age adults and elderly >35 years). Effective dose (millisievert, mSv) was calculated for chest only examinations by the following formula: DLP (mGy·cm) × 0.014 17…”

Section: Methodsmentioning

confidence: 99%

Pulmonary embolism rule out: positivity and factors affecting the yield of CT angiography

Aggarwal

Eskandari

Priya

et al. 2020

Postgraduate Medical Journal

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ObjectiveCT pulmonary angiography (CTPA) is one of the most commonly ordered CT imaging tests. It is often believed to be overutilised with few recent studies showing a yield of less than 2%. This study aimed to determine the overall positivity rate of CTPA examinations and understand the factors that affect the yield of the CTPA examination.MethodsWe retrospectively analysed 2713 patients who received the CTPA exam between 2016 and 2018. Type of study ordered (CTPA chest or CTPA chest with abdomen and pelvis CT), patient location (emergency department (ED), outpatient, inpatient, intensive care unit (ICU)) and patient characteristics—age, sex and body mass index (BMI) were recorded. A logistic regression analysis was performed to determine what factors affect the positivity rate of CT scans for pulmonary embolism (PE).ResultsWith 296 positive test results, the overall CTPA positivity was 10.9%. Male sex was associated with higher CTPA positivity, gender difference was maximum in 18-year to 35-year age group. Overweight and obese patients had significantly higher positivity as compared with BMI<25 (p<0.05). Higher positivity rate was seen in the BMI 25–40 group (11.9%) as compared with BMI>40 (10.1%) (p<0.05). Significant difference (p<0.001) was also found in CTPA examination yield from ICU (15.3%) versus inpatients (other than ICU) (12.4%) versus ED (9.6%), and outpatients (8.5%). The difference in CTPA yield based on the type of CT order (CTPA chest vs CTPA chest with CT abdomen and pelvis), patient’s age and sex was not significant.ConclusionCTPA yield of 10.9% in this study is comparable to acceptable positivity rate for the USA and is higher than recent studies showing positivity of <2%. Patient characteristics like obesity and ICU or inpatient location are associated with higher rate of CT positivity.

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“…One of these recommendations, regarding diagnosis of dyspepsia, is supported by 2 high-level studies; however, the recommendation regarding CT angiogram for pulmonary embolism in young patients is supported by a large number of several very low-level studies. A recent study reports that while younger patients are at a 10-fold lower risk for pulmonary embolism, they are imaged in similar proportions to elderly patients (2.3% vs 3.2%) [26]. These authors recommended a modification of the current guidelines regarding age-specific risk factors and found that it resulted in a decrease in the rate of imaging in young patients by 51%, with a missed PE rate of only 0.6%.…”

Section: Discussionmentioning

confidence: 99%

Choosing Wisely Canada and Diagnostic Imaging: What Level of Evidence Supports the Recommendations?

et al. 2017

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Age and sex-dependent trends in pulmonary embolism testing and derivation of a clinical decision rule for young patients

Cited by 20 publications

References 20 publications

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

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

Pulmonary embolism rule out: positivity and factors affecting the yield of CT angiography

Choosing Wisely Canada and Diagnostic Imaging: What Level of Evidence Supports the Recommendations?

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