Evaluation of Pulmonary Embolism in the Emergency Department and Consistency With a National Quality Measure

Abstract

Background The National Quality Forum (NQF) has endorsed a performance measure designed to increase imaging efficiency for the evaluation of pulmonary embolism (PE) in the emergency department (ED). To our knowledge, no published data have examined the effect of patient-level predictors on performance. Methods To quantify the prevalence of avoidable imaging in ED patients with suspected PE, we performed a prospective, multicenter observational study of ED patients evaluated for PE from 2004 through 2007 at 11 US EDs. Adult patients tested for PE were enrolled, with data collected in a standardized instrument. The primary outcome was the proportion of imaging that was potentially avoidable according to the NQF measure. Avoidable imaging was defined as imaging in a patient with low pretest probability for PE, who either did not have a D-dimer test ordered or who had a negative D-dimer test result. We performed subanalyses testing alternative pretest probability cutoffs and imaging definitions on measure performance as well as a secondary analysis to identify factors associated with inappropriate imaging. χ2 Test was used for bivariate analysis of categorical variables and multivariable logistic regression for the secondary analysis. Results We enrolled 5940 patients, of whom 4113 (69%) had low pretest probability of PE. Imaging was performed in 2238 low-risk patients (38%), of whom 811 had no D-dimer testing, and 394 had negative D-dimer test results. Imaging was avoidable, according to the NQF measure, in 1205 patients (32%; 95% CI, 31%-34%). Avoidable imaging owing to not ordering a D-dimer test was associated with age (odds ratio [OR], 1.15 per decade; 95% CI, 1.10-1.21). Avoidable imaging owing to imaging after a negative D-dimer test result was associated with inactive malignant disease (OR, 1.66; 95% CI, 1.11-2.49). Conclusions One-third of imaging performed for suspected PE may be categorized as avoidable. Improving adherence to established diagnostic protocols is likely to result in significantly fewer patients receiving unnecessary irradiation and substantial savings.

Computed tomography pulmonary angiography is overused to diagnose pulmonary embolism in the emergency department of academic community hospital

“…Among them, only 43% received further D-dimer assays as per the guidelines, while the rest underwent CTPAs without D-dimers ordered. This has been reported in previous studies documenting underutilization of the D-dimer assay in the low-risk group in emergency departments across the US [13,18]. …”

“…In other words, these patients were exposed to unnecessary risks of radiation and contrast exposure. Other studies have reported numbers of avoidable imaging ranging from as low as 33% up to 71%; the difference in the reported numbers is mainly due to differences in physicians’ practices and adherence to guidelines [14,17,18]. A very plausible explanation for these patients receiving inappropriately ordered CTPAs is that physicians did not pursue further D-dimer testing in 98% of the cases to further classify the patients as low- or high-risk patients.…”

Radiation doses to emergency department patients undergoing computed tomography

“…19,20 A recent multicentre study found that emergency physicians overuse CT in the investigation of PE and image more than half of low-risk patients. 21 One-third of ED patients evaluated for PE will later be re-evaluated with a second CT scan, despite limited diagnostic yield. 22 In our study, one in six patients scanned had a positive CT scan for PE, a rate comparable to that of a published trial of high-risk patients.…”

Association of Body Mass Index With Increased Cost of Care and Length of Stay for Emergency Department Patients With Chest Pain and Dyspnea

“…2 Although the majority of patients will ultimately have neither diagnosis, physicians order numerous laboratory tests and advanced imaging for patients with complaints referable to the chest. 2,3 Those designing clinical protocols for evaluation of possible acute coronary syndrome and PE remain keenly interested in developing guidelines that maximize patient safety by achieving a high degree of diagnostic certainty while minimizing length of stay and cost. 4,5 Toward this goal, it is important to recognize that salient patient phenotypes, such as patient body mass index (BMI), may predict more complex and costly care to achieve the same degree of diagnostic certainty as for a normal weight individual.…”