Getting to Choosing Wisely: The Value of a PE Clinical Decision Tool to Enhance Appropriateness of Care

Abstract

Pulmonary embolism (PE) is the third most common cause of cardiovascular death, affecting between 300,000 and 600,000 patients annually. Presentation is nonspecific, resulting in the reflexive decision to evaluate with computed tomography (CT) pulmonary angiography, which has a low diagnostic yield (10%-20%). However, clinical tools such as the Wells’ Criteria for Pulmonary Embolism and D-dimer levels are validated nonradiographic 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. A retrospective record review of all patients (n = 699) who underwent CT pulmonary angiography from January to June 2016 was completed. An electronic medical document using the 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. Postintervention data were then collected from November to January 2016, with a total of 458 CT scans completed. Of the 699 preintervention 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) were ruled nondiagnostic 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 patients) had a positive CT PE vs 96.8% (242 patients) 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 patients) with a negative result. Of the 458 postintervention 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% vs 3.5% (preintervention). Overuse of CT pulmonary angiography is a pervasive problem with national diagnostic rates of only 10% to 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 evidenced by the improved diagnostic rate of the internal medicine service (Fig 1), education and systematic tools (Fig 2) can effectively aid physician decision making.Fig 2Process intervention for diagnosing pulmonary embolism.View Large Image Figure ViewerDownload Hi-res image Download (PPT)