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

Deblois, Simon; Chartrand-Lefèbvre, Carl; Toporowicz, Kevin; Chen, Zhongyi; Lepanto, Luigi

doi:10.12788/jhm.2902

Cited by 36 publications

(38 citation statements)

References 37 publications

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“…Historically, most implementation strategies have failed to reduce the number of imaging tests and improve the diagnostic yield of imaging. 7 , By embedding a clinical decision support tool for ordering CTPAs in the computerized order entry system, Prevedello et al showed a small reduction in the use of CTPAs (from 26.5-24.3/1000 patients visits, p < 0.2) and an increase in the yield of CTPAs (from 9.2-12.6%, p < .01). 15 Later on, the same research group failed to further improve these outcomes implementing a performance feedback report for ED physicians.…”

Section: Discussionmentioning

confidence: 99%

“…This gap persists despite numerous efforts to improve the implementation of evidence-based diagnostic pathways. 6,7 The reasons why implementation studies to date had minimal or no impact on the use of CTPA include the perception that clinical decision support systems are complicated, have a negative impact on productivity, are not supported by a su cient body of evidence, and are not better than clinical judgement. 6,7 Why the evidence-practice gap?…”

Section: Introductionmentioning

confidence: 99%

“…Considering the barriers to the successful implementation of evidence-based diagnostic strategies highlighted in previous studies, [6][7][8] we thought it is crucial to use a clinical decision tool that is simple, safe, and supported by high level quality of evidence. Furthermore, we decided to design a multi-faceted intervention, ensuring leadership endorsement and targeting patients and healthcare workers, with a focus on physicians.…”

Section: Introductionmentioning

confidence: 99%

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Feasibility of a quality improvement project with an interrupted time series design to increase adherence to evidence-based pulmonary embolism diagnosis in the emergency department.

Germini

Afzal

et al. 2020

Preprint

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Background: Many evidence-based clinical decision tools are available for the diagnosis of pulmonary embolism (PE). However, these clinical decision tools have had suboptimal uptake in the everyday clinical practice in emergency departments (EDs), despite numerous implementation efforts. We aimed to test the feasibility of a multi-faceted intervention to implement an evidence-based PE diagnosis protocol.Methods: We conducted an interrupted time series study in three EDs in Ontario, Canada. We enrolled consecutive adult patients accessing the ED with suspected PE from January 1, 2018 to February 28, 2020. Components of the intervention were: clinical leadership endorsement; a new pathway for PE testing; physician education; personalized confidential physician feedback, and collection of patient outcome information. The intervention was implemented in November 2019. We identified six criteria for defining the feasibility outcome: successful implementation of the intervention in at least two of the three sites; capturing data on ≥ 80% of all CTPAs ordered in the EDs; timely access to electronic data; rapid manual data extraction with feedback preparation before the end of the month ≥ 80% of the time; time required for manual data extraction and feedback preparation ≤ 2 day per week in total.Results: The intervention was successfully implemented in two out of three sites. 5,094 and 899 patients were tested for PE in the period before and after the intervention, respectively. We captured data from 90% of CTPAs ordered in the EDs, and we accessed the required electronic data. The manual data extraction and individual emergency physician audit and feedback were consistently finalized before the end of each month. The time required for manual data extraction and feedback preparation was ≤ 2 days per week (14 hours).Conclusions: We proved the feasibility of implementing an evidence-based PE diagnosis protocol in two EDs. We were not successful implementing the protocol in the third ED.Registration: The study was not registered.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Feasibility of a quality improvement project with an interrupted time series design to increase adherence to evidence-based pulmonary embolism diagnosis in the emergency department.

Germini

Afzal

et al. 2020

Preprint

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“…We conducted semistructured interviews with a purposive sample of ED providers, hospitalists, and primary care physicians using an interview guide developed by the investigators. The interview guide was informed by the Consolidated Framework for Implementation Research (CFIR) and the Theoretical Domains Framework (TDF) and recent systematic review of strategies to improve the evidence‐based diagnosis of PE . The CFIR, composed of five domains—inner setting, outer setting, process, individual characteristics, and intervention characteristics—emphasizes determinants of implementation primarily at the organizational level .…”

Section: Methodsmentioning

confidence: 99%

“…For example, in a recent study, providers overrode the EHR‐integrated CDS and proceeded to CTPA in 96% of cases . These studies did not use implementation science principles, specifically geared to help promote the uptake of evidence‐based practices, to deliver the interventions, and it is possible that the use of implementation science could improve the uptake of evidence‐based diagnostic approaches …”

Section: Introductionmentioning

confidence: 99%

Provider Perspectives on the Use of Evidence‐based Risk Stratification Tools in the Evaluation of Pulmonary Embolism: A Qualitative Study

Westafer

Kunz

Bugajska

et al. 2020

Academic Emergency Medicine

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Objectives Providers often pursue imaging in patients at low risk of pulmonary embolism (PE), resulting in imaging yields <10% and false‐positive imaging rates of 10% to 25%. Attempts to curb overtesting have had only modest success and no interventions have used implementation science frameworks. The objective of this study was to identify barriers and facilitators to the adoption of evidence‐based diagnostic testing for PE. Methods We conducted semistructured interviews with a purposeful sample of providers. An interview guide was developed using the implementation science frameworks, consolidated framework for implementation research, and theoretical domains framework. Interviews were recorded, transcribed, and analyzed in an iterative process. Emergent themes were identified, discussed, and organized. Results We interviewed 23 providers from four hospital systems, and participants were diverse with regard to years in practice and practice setting. Barriers were predominately at the provider level and included lack of knowledge of the tools, particularly misunderstanding of the validated scoring systems in Wells, as well as risk avoidance and need for certainty. Barriers to prior implementation strategies included the perception of a clinical decision support (CDS) tool for PE as adding steps with little value; most participants reported that they overrode CDS interventions because they had already made the decision. All providers identified institution‐level strategies as facilitators to use, including endorsed guidelines, audit feedback with peer comparison about imaging yield, and peer pressure. Conclusions This exploration of the use of risk stratification tools in the evaluation of PE found that barriers to use primarily exist at the provider level, whereas facilitators to the use of these tools are largely perceived at the level of the institution. Future efforts to promote the evidence‐based diagnosis of PE should be informed by these determinants.

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

et al. 2021

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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.

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

Cited by 36 publications

References 37 publications

Feasibility of a quality improvement project with an interrupted time series design to increase adherence to evidence-based pulmonary embolism diagnosis in the emergency department.

Feasibility of a quality improvement project with an interrupted time series design to increase adherence to evidence-based pulmonary embolism diagnosis in the emergency department.

Provider Perspectives on the Use of Evidence‐based Risk Stratification Tools in the Evaluation of Pulmonary Embolism: A Qualitative Study

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

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