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Does Clinical Decision Support Reduce Unwarranted Variation in Yield of CT Pulmonary Angiogram?

Am J Med. 2013 Nov;126(11):975-81

Authors: Prevedello LM, Raja AS, Ip IK, Sodickson A, Khorasani R

Abstract
OBJECTIVE: The study objective was to determine whether previously documented effects of clinical decision support on computed tomography for pulmonary embolism in the emergency department (ie, decreased use and increased yield) are due to a decrease in unwarranted variation. We evaluated clinical decision support effect on intra- and inter-physician variability in the yield of pulmonary embolism computed tomography (PE-CT) in this setting.
METHODS: The study was performed in an academic adult medical center emergency department with 60,000 annual visits. We enrolled all patients who had PE-CT performed 18 months pre- and post-clinical decision support implementation. Intra- and inter-physician variability in yield (% PE-CT positive for acute pulmonary embolism) were assessed. Yield variability was measured using logistic regression accounting for patient characteristics.
RESULTS: A total of 1542 PE-CT scans were performed before clinical decision support, and 1349 PE-CT scans were performed after clinical decision support. Use of PE-CT decreased from 26.5 to 24.3 computed tomography scans/1000 patient visits after clinical decision support (P < .02); yield increased from 9.2% to 12.6% (P < .01). Crude inter-physician variability in yield ranged from 2.6% to 20.5% before clinical decision support and from 0% to 38.1% after clinical decision support. After controlling for patient characteristics, the post-clinical decision support period showed significant inter-physician variability (P < .04). Intra-physician variability was significant in 3 of the 25 physicians (P < .04), all with increased yield post-clinical decision support.
CONCLUSIONS: Overall PE-CT yield increased after clinical decision support implementation despite significant heterogeneity among physicians. Increased inter-physician variability in yield after clinical decision support was not explained by patient characteristics alone and may be due to variable physician acceptance of clinical decision support. Clinical decision support alone is unlikely to eliminate unwarranted variability, and additional strategies and interventions may be needed to help optimize acceptance of clinical decision support to maximize returns on national investments in health information technology.

PMID: 24157288 [PubMed - in process]

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Computed Tomography and Echocardiography in Patients With Acute Pulmonary Embolism: Part 1: Correlation of Findings of Right Ventricular Enlargement.

J Thorac Imaging. 2013 Oct 22;

Authors: Wake N, Kumamaru KK, George E, Bedayat A, Ghosh N, Gonzalez Quesada C, Rybicki FJ, Gerhard-Herman M

Abstract
PURPOSE:: To evaluate the correlation between the computed tomography (CT)-derived right ventricle (RV) to left ventricle (LV) diameter ratio and the RV size determined by echocardiography in patients with acute pulmonary embolism.
MATERIALS AND METHODS:: Consecutive CT pulmonary angiography examinations (August 2003 to May 2010) from a single, large, urban teaching hospital were retrospectively reviewed. For a cohort of 777 subjects who underwent echocardiography within 48 hours of the CT acquisition, the qualitative RV size (divided into 5 categories) extracted from the echocardiography report was correlated with the CT-derived RV/LV diameter ratio.
RESULTS:: There was moderate correlation (Spearman rank correlation coefficient=0.54, P<0.001) between the CT-derived RV/LV ratio and the RV size as determined by echocardiography. The correlation coefficient and the concordance rate were inversely related to the time difference between the acquisitions of the 2 modalities.
CONCLUSIONS:: CT and echocardiography findings to assess the RV size after acute pulmonary embolism have moderate correlation.

PMID: 24157621 [PubMed - as supplied by publisher]

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Computed Tomography and Echocardiography in Patients With Acute Pulmonary Embolism: Part 2: Prognostic Value.

J Thorac Imaging. 2013 Oct 22;

Authors: George E, Kumamaru KK, Ghosh N, Gonzalez Quesada C, Wake N, Bedayat A, Dunne RM, Saboo SS, Khandelwal A, Hunsaker AR, Rybicki FJ, Gerhard-Herman M

Abstract
PURPOSE:: The aim of the study was to compare the prognostic value of right ventricular (RV) dysfunction detected on computed tomography pulmonary angiography (CTPA) and transthoracic echocardiography (TTE) in patients with acute pulmonary embolism (PE).
MATERIALS AND METHODS:: From all consecutive CTPAs performed between August 2003 and May 2010 that were positive for acute PE (n=1744), those with TTE performed within 48 hours of CTPA (n=785) were selected as the study cohort. Multivariate logistic regression analysis was performed to assess the association of CTPA RV/left ventricular (LV) diameter ratio and TTE RV strain with PE-related 30-day mortality, including other associated factors as covariates. The predictive ability (area under the curve) was compared between the model including the CT RV/LV diameter ratio and that including TTE RV strain. Test characteristics of the 2 modalities were calculated.
RESULTS:: Both CT RV/LV diameter ratio and TTE RV strain were independently associated with PE-related 30-day mortality (adjusted odds ratio=1.14, P=0.023 for 0.1 increment of the CT RV/LV diameter ratio; and odds ratio=2.13, P=0.041 for TTE RV strain). History of congestive heart failure and malignancy were independent predictors of PE-related mortality, while there was significantly lower mortality associated with anticoagulation use. The model including TTE RV strain and that including CT RV/LV had similar predictive ability (area under the curve=0.80 vs. 0.81, P=0.50). The sensitivity, specificity, and positive and negative predictive values of TTE RV strain and CT RV/LV diameter ratio at a cutoff of ≥1.0 were similar for PE-related 30-day mortality.
CONCLUSIONS:: Both RV strain on TTE and an increased CT RV/LV diameter ratio are predictors of PE-related 30-day mortality with similar prognostic significance.

PMID: 24157622 [PubMed - as supplied by publisher]

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Influence of C-reactive protein levels and age on the value of D-dimer in diagnosing Pulmonary Embolism.

Eur J Haematol. 2013 Oct 25;

Authors: Crop MJ, Siemes C, Berendes P, van der Straaten F, Willemsen S, Levin MD

Abstract
BACKGROUND: Recently the number of performed CT-angiographies to diagnose pulmonary embolism (PE) rised markedly, while the incidence of PE hardly increased. This low yield of CT-angiography leads to more patients exposed to radiation and higher costs.
AIM: The diagnostic value of age, C-reactive protein (CRP) and D-dimer in PE was investigated. Additionally an age-adjusted D-dimer cut-off level [age-adjusted cut-off=age/100mg/L] was compared to the conventional cut-off level in diagnosing PE for patients ≥50 years.
METHODS: This observational study (2004-2007) included all consecutive patients suspected for PE presenting on the Emergency Department with a performed CT-angiography after measuring CRP and D-dimer levels.
RESULTS: Of 4609 patients suspected for PE, 1164 patients underwent CT-angiography of whom 309 (26.5%) had PE. Correlation between CRP and D-dimer was 0.42 (p<0.001). D-dimer and age correlated positively (rs =0.33,p<0.001), but only in patients >50 years and independent of PE. Multivariate regression analysis showed significant contribution of age, D-dimer and age-adjusted D-dimer for diagnosing PE, but not for CRP. Using an age-adjusted D-dimer cut-off value increased specificity from 37% to 50%, whereas sensitivity declined from 96% to 90%. Applying this age-adjusted cut-off level in patients above ≥70 years, specificity increased from 18% to 40%, while sensitivity decreased from 96% to 88%.
CONCLUSIONS: In the prediction of PE, age and D-dimer levels are relevant, while CRP level is not. Using an age-adjusted D-dimer cut-off in older patients remarkably improves the specificity of D-dimer testing with a minor decline in sensitivity. This may increase the yield of CT-angiography in diagnosing PE. This article is protected by copyright. All rights reserved.

PMID: 24164492 [PubMed - as supplied by publisher]