Abstract
In response to calls to reduce unnecessary diagnostic testing with computed tomographic pulmonary angiography (CTPA) for suspected pulmonary embolism (PE), there have been growing efforts to create and implement decision rules for PE testing. It is unclear if the use of advanced imaging tests for PE has diminished over time. To assess the use of advanced imaging tests, including chest computed tomography (CT) (ie, all chest CT except for CTPA), CTPA, and ventilation-perfusion (V/Q) scan, for PE from 2004 to 2016. Cohort study of adults by age group (18-64 years and ≥65 years) enrolled in 7 US integrated and mixed-model health care systems. Joinpoint regression analysis was used to identify years with statistically significant changes in imaging rates and to calculate average annual percentage change (growth) from 2004 to 2007, 2008 to 2011, and 2012 to 2016. Analyses were conducted between June 11, 2019, and March 18, 2020. Rates of chest CT, CTPA, and V/Q scan by year and age, as well as annual change in rates over time. Overall, 3.6 to 4.8 million enrollees were included each year of the study, for a total of 52 343 517 person-years of follow-up data. Adults aged 18 to 64 years accounted for 42 223 712 person-years (80.7%) and those 65 years or older accounted for 10 119 805 person-years (19.3%). Female enrollees accounted for 27 712 571 person-years (52.9%). From 2004 and 2016, chest CT use increased by 66.3% (average annual growth, 4.4% per year), CTPA use increased by 450.0% (average annual growth, 16.3% per year), and V/Q scan use decreased by 47.1% (decreasing by 4.9% per year). The use of CTPA increased most rapidly from 2004 to 2006 (44.6% in those aged 18-64 years and 43.9% in those ≥65 years), with ongoing rapid growth from 2006 to 2010 (annual growth, 19.8% in those aged 18-64 years and 18.3% in those ≥65 years) and persistent but slower growth in the most recent years (annual growth, 4.3% in those aged 18-64 years and 3.0% in those ≥65 years from 2010 to 2016). The use of V/Q scanning decreased steadily since 2004. From 2004 to 2016, rates of chest CT and CTPA for suspected PE continued to increase among adults but at a slower pace in more contemporary years. Efforts to combat overuse have not been completely successful as reflected by ongoing growth, rather than decline, of chest CT use. Whether the observed imaging use was appropriate or was associated with improved patient outcomes is unknown.
Highlights
Venous thromboembolism is a common and potentially fatal disease, with an estimated lifetime prevalence of up to 5%.1 Approximately 20% of individuals with pulmonary embolism (PE) die before diagnosis or on the first day after their diagnosis.[1,2] Because the signs and symptoms of PE are often nonspecific, advanced imaging is commonly used for the diagnosis.[2]
From 2004 and 2016, chest computed tomography (CT) use increased by 66.3%, computed tomographic pulmonary angiography (CTPA) use increased by 450.0%, and V/Q scan use decreased by 47.1%
From 2004 to 2016, rates of chest CT and CTPA for suspected PE continued to increase among adults but at a slower pace in more contemporary years
Summary
Venous thromboembolism is a common and potentially fatal disease, with an estimated lifetime prevalence of up to 5%.1 Approximately 20% of individuals with pulmonary embolism (PE) die before diagnosis or on the first day after their diagnosis.[1,2] Because the signs and symptoms of PE are often nonspecific, advanced imaging is commonly used for the diagnosis.[2]. In 2001, CT (including CTPA) was used in 2.6% of ED visits for chest pain or shortness of breath, which increased to 12.5% in 2009, with an average growth of 28.1% per year.[7] In an analysis of Medicare beneficiaries with suspected PE8 from 2002 to 2009, chest CT use increased 5-fold, but positivity rates (yield) decreased from 7.3% in 2002 to 5.9% in 2009 This finding suggests that a smaller percentage of patients have received the potential benefit of CTPA with respect to improved detection, and more patients have experienced potential harms, including exposure to ionizing radiation, intravenous contrast,[9,10] and overdiagnosis. This observation is further supported by an increasing incidence of PE, with a lower case mortality rate but no change in overall PE mortality.[10,11,12]
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