Getting to Choosing Wisely: The Value of a PE Clinical Decision Tool to Enhance Appropriateness of Care
Hallie E. Baer, MD, Taylor D. Hicks, MD, Georges M. Haidar, MD, Maureen K. Sheehan, MD, Matthew J. Sideman, MD, Lori L. Pounds, MD, Mark G. Davies, MD, PhD, MBA.
University of Texas Health San Antonio, San Antonio, TX, USA.
Objective(s): Pulmonary embolism is the third most common cause of cardiovascular death, affecting between 300,000 to 600,000 patients annually. Presentation is non-specific, resulting in the reflexive decision to evaluate with computed tomography pulmonary angiography, which has a low diagnostic yield (10-20%). However, clinical tools such as Wells' Criteria and D-dimer levels are validated non-radiographic methods to rule out PE and effectively reduce diagnostic time, cost, and potential complications. The aim of this study was to determine diagnostic yield and implement a clinical decision making tool to reduce overutilization.
Methods: A retrospective chart review of all patients (699) who underwent CT pulmonary angiography from January to June 2016 was completed. Results were classified as positive, negative, or non-diagnostic based on the final report by board-certified radiologist. An electronic medical document utilizing Wells criteria was then created with embedded order links for D-Dimer and CT pulmonary angiography based on score. Physician education and introduction of the document was focused on the internal medicine services. Post-intervention data was then collected from November to January 2016 with a total of 458 CT scans completed.
Results: Of the 699 pre-intervention studies reviewed, a positive CT PE result was present in 7.3% (51 patients), 91.5% (639 patients) were negative, and 1.3% (9 patients) ruled non-diagnostic due to contrast timing or motion artifact. Of the 35.8% (250 patients) who were assigned a low modified Wells Score (≤4), only 2% (5) had a positive CT PE vs. 96.8% (242) with a negative result. For patients with a high modified Wells Score, 10.2% (46 patients) had a positive CT PE vs. 88.4% (397) with a negative result. Of the 458 post-intervention studies reviewed, a positive CT PE result was present in 7.4% (34 patients). However, the diagnostic yield for the interval medicine service was 10.9% versus 3.5% (pre-intervention).
Conclusions: Overutilization of CT Pulmonary Angiography is a pervasive problem with national diagnostic rates of only 10-20%. Our results demonstrate a diagnostic rate below the national average, but confirm the well-established validity of Wells Criteria as a clinical decision making tool. Furthermore, as evidence by the improved diagnostic rate of the internal medicine service, education and systematic tools can effectively aid physician decision making.
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