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

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.

• Authors: Martin Rohacek, Janet Buatsi, Zsolt Szucs-Farkas, Birgit Kleim, Heinz Zimmermann, Aristomenis Exadaktylos, Christoforos Stoupis
• Journal: Intensive care medicine (Intensive Care Med) Vol. 38 Issue 8 Pg. 1345-51 (Aug 2012) ISSN: 1432-1238 [Electronic] United States
• PMID: 22584801 (Publication Type: Journal Article)

Chemical References

• Fibrin Fibrinogen Degradation Products
• fibrin fragment D

Topics

• Defensive Medicine
• Diagnostic Errors (prevention & control)
• Emergency Service, Hospital
• Female
• Fibrin Fibrinogen Degradation Products (analysis)
• Humans
• Male
• Middle Aged
• Practice Patterns, Physicians' (statistics & numerical data)
• Pulmonary Artery (diagnostic imaging)
• Pulmonary Embolism (diagnosis)
• Surveys and Questionnaires
• Tomography, X-Ray Computed