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

Abstract

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.

Clinicians' perspectives on the implementation of patient decision aids in the emergency department: A qualitative interview study

“…Although qualitative studies have explored clinician attitudes toward SDM in general 23 and toward the use of evidence‐based risk‐stratification tools, 24 our study is the first to specifically explore the implementation of DAs to facilitate SDM in the ED setting. SDM has been lauded as a method to deliver high‐quality, patient‐centered care in the ED, 1 , 2 , 25 and DAs have been identified as a means to facilitate and standardize the delivery of SDM.…”

Crucial considerations: Sex differences in the epidemiology, diagnosis, treatment, and outcomes of acute pulmonary embolism in non‐pregnant adult patients

“…62 receive diagnostic imaging to assess for PE. [63][64][65][66] Of note, both the PERC derivation and validation cohorts were approximately twothirds women. Sex was evaluated in the derivation study but was not found to be significant and therefore is not included in the decision tool.…”

A Systematic Approach to Identifying and Developing Implementation Strategies to Support the Uptake of a Risk Tool to Aid in Clinical Management of Patients with Syncope: A Qualitative Study

“…Key barriers included uncertainty around when and how to apply the CSRS recommendations, lack of resources (e.g., cardiac monitors), lack of buy-in from the broader medical team, discomfort (hesitancy) using CSRS, and lack of evidence about the impact on patient outcomes. Surprisingly, no reference on workload or time constraint was brought up, as is often found in other studies (39)(40)(41)(42). Our ndings suggest that physician capability should be a central target of implementation supports, speci cally the capability to interpret CSRSbased criteria and apply it across a range of clinical presentations.…”

“…In our study, participants largely referred to educational meetings (e.g., combined grand rounds inclusive of all relevant specialities) and educational videos. Skill-building can be supplemented by creating increased opportunity to utilize the CSRS, including integration into the EMR, engaging local champions, displaying posters, and sending e-mail communications to encourage use (41,42,46). This suite of strategies are commonly used in the ED setting (46) and have demonstrated effectiveness in promoting guideline-adherent care (47).…”