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Ordering CT pulmonary angiography to exclude pulmonary embolism: defense versus evidence in the emergency room

Martin Rohacek| Janet Buatsi| Zsolt Szucs-Farkas| Birgit Kleim| Heinz Zimmermann| Aristomenis Exadaktylos| Christoforos Stoupis
Original
Volume 38, Issue 8 / August , 2012

Pages 1345 - 1351

Abstract

Purpose

To identify reasons for ordering computed tomography pulmonary angiography (CTPA), to identify the frequency of reasons for CTPA reflecting defensive behavior and evidence-based behavior, and to identify the impact of defensive medicine and of training about diagnosing pulmonary embolism (PE) on positive results of CTPA.

Methods

Physicians in the emergency department of a tertiary care hospital completed a questionnaire before CTPA after being trained about diagnosing PE and completing questionnaires.

Results

Nine hundred patients received a CTPA during 3 years. For 328 CTPAs performed during the 1-year study period, 140 (43 %) questionnaires were completed. The most frequent reasons for ordering a CTPA were to confirm/rule out PE (93 %), elevated D-dimers (66 %), fear of missing PE (55 %), and Wells/simplified revised Geneva score (53 %). A positive answer for “fear of missing PE” was inversely associated with positive CTPA (OR 0.36, 95 % CI 0.14–0.92, p = 0.033), and “Wells/simplified revised Geneva score” was associated with positive CTPA (OR 3.28, 95 % CI 1.24–8.68, p = 0.017). The proportion of positive CTPA was higher if a questionnaire was completed, compared to the 2-year comparison period (26.4 vs. 14.5 %, OR 2.12, 95 % CI 1.36–3.29, p < 0.001). The proportion of positive CTPA was non-significantly higher during the study period than during the comparison period (19.2 vs. 14.5 %, OR 1.40, 95 % CI 0.98–2.0, p = 0.067).

Conclusion

Reasons for CTPA reflecting defensive behavior—such as “fear of missing PE”—were frequent, and were associated with a decreased odds of positive CTPA. Defensive behavior might be modifiable by training in using guidelines.

Keywords

References

  1. Oger E (2000) Incidence of venous thromboembolism: a community-based study in Western France. EPI-GETBP Study Group. Groupe d’Etude de la Thrombose de Bretagne Occidentale. Thromb Haemost 83:657–660
    • View reference on PubMed
  2. Spencer FA, Emery C, Lessard D, Anderson F, Emani S, Aragam J, Becker RC, Goldberg RJ (2006) The Worcester venous thromboembolism study: a population-based study of the clinical epidemiology of venous thromboembolism. J Gen Intern Med 21:722–727
    • View reference on PubMed
    • View reference on publisher's website
  3. Goldhaber SZ, Visani L, De Rosa M (1999) Acute pulmonary embolism: clinical outcomes in the International Cooperative Pulmonary Embolism Registry (ICOPER). Lancet 353:1386–1389
    • View reference on PubMed
    • View reference on publisher's website
  4. Agnelli G, Becattini C (2010) Acute pulmonary embolism. N Engl J Med 363:266–274
    • View reference on PubMed
    • View reference on publisher's website
  5. Wells PS, Anderson DR, Rodger M, Ginsberg JS, Kearon C, Gent M, Turpie AG, Bormanis J, Weitz J, Chamberlain M, Bowie D, Barnes D, Hirsh J (2000) Derivation of a simple clinical model to categorize patients probability of pulmonary embolism: increasing the models utility with the SimpliRED D-dimer. Thromb Haemost 83:416–420
    • View reference on PubMed
  6. Klok FA, Mos IC, Nijkeuter M, Righini M, Perrier A, Le Gal G, Huisman MV (2008) Simplification of the revised Geneva score for assessing clinical probability of pulmonary embolism. Arch Intern Med 168:2131–2136
    • View reference on PubMed
    • View reference on publisher's website
  7. Hermer LD, Brody H (2010) Defensive medicine, cost containment, and reform. J Gen Intern Med 25:470–473
    • View reference on PubMed
    • View reference on publisher's website
  8. Studdert DM, Mello MM, Sage WM, DesRoches CM, Peugh J, Zapert K, Brennan TA (2005) Defensive medicine among high-risk specialist physicians in a volatile malpractice environment. JAMA 293:2609–2617
    • View reference on PubMed
    • View reference on publisher's website
  9. Khemani RG, Sward K, Morris A, Dean JM, Newth CJ (2011) Variability in usual care mechanical ventilation for pediatric acute lung injury: the potential benefit of a lung protective computer protocol. Intensive Care Med 37:1840–1848
  10. Jena AB, Seabury S, Lakdawalla D, Chandra A (2011) Malpractice risk according to physician specialty. N Engl J Med 365:629–636
    • View reference on PubMed
    • View reference on publisher's website
  11. Di Nisio M, Squizzato A, Rutjes AW, Buller HR, Zwinderman AH, Bossuyt PM (2007) Diagnostic accuracy of D-dimer test for exclusion of venous thromboembolism: a systematic review. J Thromb Haemost 5:296–304
    • View reference on PubMed
    • View reference on publisher's website
  12. Carrier M, Righini M, Djurabi RK, Huisman MV, Perrier A, Wells PS, Rodger M, Wuillemin WA, Le Gal G (2009) VIDAS D-dimer in combination with clinical pre-test probability to rule out pulmonary embolism. A systematic review of management outcome studies. Thromb Haemost 101:886–892
    • View reference on PubMed
  13. Eagles D, Stiell IG, Clement CM, Brehaut J, Taljaard M, Kelly AM, Mason S, Kellermann A, Perry JJ (2008) International survey of emergency physicians’ awareness and use of the Canadian cervical-spine rule and the Canadian computed tomography head rule. Acad Emerg Med 15:1256–1261
    • View reference on PubMed
    • View reference on publisher's website
  14. Rohacek M, Albrecht M, Kleim B, Zimmermann H, Exadaktylos A (2012) Reasons for ordering computed tomography scans of the head in patients with minor brain injury. Injury. doi:10.1016/j.injury.2012.01.001
  15. Boehnert MU, Zimmermann H, Exadaktylos AK (2009) O knowledge, where art thou? Evidence and suspected appendicitis. J Eval Clin Pract 15:1177–1179
    • View reference on PubMed
    • View reference on publisher's website
  16. Katz DA, Williams GC, Brown RL, Aufderheide TP, Bogner M, Rahko PS, Selker HP (2005) Emergency physicians’ fear of malpractice in evaluating patients with possible acute cardiac ischemia. Ann Emerg Med 46:525–533
    • View reference on PubMed
    • View reference on publisher's website
  17. Singh B, Parsaik AK, Agarwal D, Surana A, Mascarenhas SS, Chandra S (2011) Diagnostic accuracy of pulmonary embolism rule-out criteria: a systematic review and meta-analysis. Ann Emerg Med. doi:10.1016/j.annemergmed.2011.10.022
  18. Mello MM, Chandra A, Gawande AA, Studdert DM (2010) National costs of the medical liability system. Health Aff (Millwood) 29:1569–1577
    • View reference on publisher's website
  19. Malach M, Baumol WJ (2012) Opportunities for cost reduction of medical care: part 3. J Community Health. doi:10.1007/s10900-011-9534-8
  20. Asch DA, Jedrziewski MK, Christakis NA (1997) Response rates to mail surveys published in medical journals. J Clin Epidemiol 50:1129–1136
    • View reference on PubMed
    • View reference on publisher's website

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