Variation in the utilization and positivity rates of CT pulmonary angiography among emergency physicians at a tertiary academic emergency department

Abstract

We examined the patient and physician characteristics related to the use and yield of computed tomography pulmonary angiogram (CTPA) for the diagnosis of pulmonary embolism (PE) at a tertiary academic hospital emergency department (ED). A cross-sectional retrospective study was conducted on 835 consecutive ED patients with suspected PE who underwent CTPA. Radiology report data were extracted from our institution's RIS PACS software (Syngo Imaging, Siemens) based on a targeted search of all CTPA reports from 2010 to 2012. Utilization and PE positivity rates of CTPA were calculated and correlated with patient characteristics including age and gender, as well as emergency physician (EP) characteristics including gender, years in practice, and training certification. Acute PE was diagnosed in 17.8 % of patients. A further 32.9 % of the scans were negative for PE but had other clinically significant findings. We found higher utilization rates in female and older patients (p < 0.001), however, without corresponding differences in PE positivity rates compared to their male and younger counterparts. There was a high inter-physician variation in CTPA utilization rate (range 0.21-0.77 scans per 100 patients seen) and PE positivity rate (range 6.7-38.9 %). However, neither rates correlated with EP years of experience (p > 0.15 with cut-offs at 5, 10, and 20 years post-residency), gender (p = 0.59), or training certification (p = 0.56 between EPs certified by the 5-year program of the Royal College of Physicians of Canada versus the 3-year program of the College of Family Physicians of Canada). Our study demonstrated considerable inter-physician variability in the utilization and PE positivity rates of CTPA. These results suggest an opportunity for a more standardized approach to the use of CTPA among EPs at our institution.

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

“…[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.…”

“…[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.…”

Limited Hospital Variation in the Use and Yield of CT for Pulmonary Embolism in Patients Undergoing Total Hip or Total Knee Replacement Surgery

“…Overuse of this technology has been discussed intensely based on low reported positivity rates (,10%) (1,5,7-9), but these data generally are derived from single-institution studies or from multicenter trials that include fewer than 10 institutions. Moreover, most of the previous reports on CT use in PE detection focus on patients in the area of emergency medicine (10). Evaluation of nationwide use HEALTH POLICY AND PRACTICE: Use and Yield of CT for Pulmonary Embolism Kumamaru et al with the Pearson x 2 test.…”

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.

“…2 Despite high quality evidence supporting the use of these diagnostic algorithms, published data show that these tools are seldom used in everyday clinical practice. [3][4][5][6] The main effect of this is the over-use of CTPA, which translates into excess radiation exposure, the possibility of contrast-induced nephropathy, overtreatment, and reduction of health system e ciency and resources. This gap persists despite numerous efforts to improve the implementation of evidence-based diagnostic pathways.…”