Underutilization of guideline-recommended risk stratification tools for reducing unnecessary computed tomography pulmonary angiography (CTPA) in the emergency department has been reported among patients with suspected pulmonary embolism (PE), according to results of an analysis published in the European Heart Journal – Quality of Care and Clinical Outcomes. Researchers conducted a retrospective, observational, single-center study among patients from the Turku University Hospital, Emergency Clinic, located in Turku, Finland.
The researchers sought to examine the indications for CTPA in the emergency clinic at a Finnish hospital and the factors that may contribute to overutilization of this technique. With use of a structured case report form, data from a total of 1001 patients were collected retrospectively between January 1, 2014, and December 31, 2016. The participants included in the analysis had undergone CTPA for any indication in the emergency clinic during the study period. If a patient had undergone several CTPAs during this time frame, only the first CTPA was included.
Overall, PE was diagnosed in 22.2% (222 of 1001) of participants. Those patients with PE more often had a prior diagnosis of PE/deep vein thrombosis, bleeding/ thrombotic diathesis, and less often had a prior diagnosis of asthma, chronic obstructive pulmonary disease, decompensated heart failure, or coronary artery disease. Further, patients with PE more often experienced dyspnea, unilateral lower extremity palpation pain, and unilateral edema.
All of the participants were divided into 3 groups based on Wells PE risk stratification score and into 2 groups based on revised Geneva score. According to Wells risk scores, 2.4% (9 of 382), 31.5% (166 of 527), and 51.1% (47 of 92) of patients had PE in the CTPA in the low, intermediate, and high pretest likelihood groups, respectively. According to revised Geneva risk scores, 20.9% (200 of 955) and 47.8% (22 of 46) of patients had PE in the CTPA in the low-intermediate and the high pretest likelihood groups, respectively.
Of note, 10.5% (105 of 1001) and 10.7% (107 of 1001) of the CTPAs were inappropriately ordered, based on Wells scores and the revised Geneva scores, respectively. Overall, 16.8% (168 of 1001) of the CTPAs could thus theoretically be avoided.
A major limitation of the current analysis is the fact that since this was a single-center, observational study, data were collected from the available medical records, and thus the possibility for residual confounding exists. The investigators concluded that the findings from this study highlight the use of guideline-recommended risk stratification tools for decreasing unnecessary CTPA.
Disclosure: Several study authors declared affiliations with the pharmaceutical industry. Please see the original reference for a full list of authors’ disclosures.
Kauppi JM, Airaksinen KEJ, Saha J, et al. Adherence to risk-assessment protocols to guide computed tomography pulmonary angiography in patients with suspected pulmonary embolism. Eur Heart J Qual Care Clin Outcomes. Published online March 16, 2021. doi:10.1093/ehjqcco/qcab020.