Electronic pulmonary embolism clinical decision support and effect on yield of computerized tomographic pulmonary angiography: ePE—A pragmatic prospective cohort study

Abstract

Objective Multiple professional societies recommend pre‐test probability (PTP) assessment prior to imaging in the evaluation of patients with suspected pulmonary embolism (PE), however, PTP testing remains uncommon, with imaging occurring frequently and rates of confirmed PE remaining low. The goal of this study was to assess the impact of a clinical decision support tool embedded into the electronic health record to improve the diagnostic yield of computerized tomography pulmonary angiography (CTPA) in suspected patients with PE in the emergency department (ED). Methods Between July 24, 2014 and December 31, 2016, 4 hospitals from a healthcare system embedded an optional electronic clinical decision support system to assist in the diagnosis of pulmonary embolism (ePE). This system employs the Pulmonary Embolism Rule‐out Criteria (PERC) and revised Geneva Score (RGS) in series prior to CT imaging. We compared the diagnostic yield of CTPA) among patients for whom the physician opted to use ePE versus the diagnostic yield of CTPA when ePE was not used. Results During the 2.5‐year study period, 37,288 adult patients were eligible and included for study evaluation. Of eligible patients, 1949 of 37,288 (5.2%) were enrolled by activation of the tool. A total of 16,526 CTPAs were performed system‐wide. When ePE was not engaged, CTPA was positive for PE in 1556 of 15,546 scans for a positive yield of 10.0%. When ePE was used, CTPA identified PE in 211 of 980 scans (21.5% yield) ( P < 0.001). Conclusions ePE significantly increased the diagnostic yield of CTPA without missing 30‐day clinically overt PE.

Computed Tomography Angiography for Detection of Pulmonary Embolism in Western Australia Shows Increasing Use with Decreasing Diagnostic Yield

“…In relation to PE, evidence-based clinical decision support systems (CDS) have been shown to improve diagnostic yield [19,20], and WA Health provides these in relation to CTPA [18] although they may not always be used. In patients suspected of PE, the obvious way forward is to embed a pre-test probability assessment in the ED workflow using electronic health records to present CDS related to PE diagnostic strategies to the ED physician [46]. Such systems have been shown to decrease advanced imaging use, improve the diagnostic yield of CTPA, and reduce non-adherence to pre-test probability assessment [46].…”

“…In patients suspected of PE, the obvious way forward is to embed a pre-test probability assessment in the ED workflow using electronic health records to present CDS related to PE diagnostic strategies to the ED physician [46]. Such systems have been shown to decrease advanced imaging use, improve the diagnostic yield of CTPA, and reduce non-adherence to pre-test probability assessment [46]. Similar international research has suggested that mandating the recording of Wells scores and Ddimer values on CTPA request forms increases diagnostic yield [47], although such policies may oversimplify the role of clinical judgement.…”

Improving Adherence to Pulmonary Embolism Evaluation Consensus Guidelines: A Multimodal Approach

“…Clinical Decision Support (CDS) systems have been well studied; however, results have varied substantially, with multiple noting nonsignificant changes to positivity rates 6-8 .…”

Sustainability of a Clinical Decision Support Intervention for Outpatient Care for Emergency Department Patients With Acute Pulmonary Embolism

“…7 EHR-embedded decision support can improve physician decision-making, 17,18 even in busy EDs. 17,19 But effect durability has not been well studied. To be sustainable, practice innovations must continue their impact in the absence of their initial promotion and must adapt to changing conditions and evidence.…”

“…EHR-embedded decision support can improve physician decision-making, even in busy EDs . But effect durability has not been well studied.…”