The use of decision support to measure documented adherence to a national imaging quality measure

RATIONALE AND OBJECTIVES: Present methods for measuring adherence to national imaging quality measures often require a resource-intensive chart review. Computerized decision support systems may allow for automated capture of these data. We sought to determine the feasibility of measuring adherence to a national quality measure (NQM) regarding computed tomography pulmonary angiograms (CTPAs) for pulmonary embolism using measure-targeted clinical decision support and whether the associated increased burden of data captured required by this system would affect the use and yield of CTs. MATERIALS AND METHODS: This institutional review board-approved prospective cohort study enrolled patients from September 1, 2009, through November 30, 2011, in the emergency department (ED) of a 776-bed quaternary-care adults-only academic medical center. Our intervention consisted of an NQM-targeted clinical decision support tool for CTPAs, which required mandatory input of the Wells criteria and serum D-dimer level. The primary outcome was the documented adherence to the quality measure prior and subsequent to the intervention, and the secondary outcomes were the use and yield of CTPAs. RESULTS: A total of 1209 patients with suspected PE (2.0% of 58,795 ED visits) were imaged by CTPA during the 12-month control period, and 1212 patients were imaged in the 12 months after the quarter during which the intervention was implemented (2.0% of 59,478 ED visits, P = .84). Documented baseline adherence to the NQM was 56.9% based on a structured review of the provider notes. After implementation, documented adherence increased to 75.6% (P \u3c .01). CTPA yield remained unchanged and was 10.4% during the control period and 10.1% after the intervention (P = .88). CONCLUSIONS: Implementation of a clinical decision support tool significantly improved documented adherence to an NQM, enabling automated measurement of provider adherence to evidence without the need for resource-intensive chart review. It did not adversely affect the use or yield of CTPAs

Predictors of Overtesting in Pulmonary Embolism Diagnosis

© 2019 Background: The benefits of computed tomography pulmonary angiography (CTPA) for pulmonary embolism (PE) diagnosis must be weighed against its risks, radiation-induced malignancy, and contrast-induced nephropathy. Appropriate use of CTPA can be assessed by monitoring yield, the percentage of tests positive for PE. We identify factors that are associated low CTPA yield, which may predict overtesting. Methods: This was a retrospective cohort study of six emergency departments between June 2014 and February 2017. The electronic health record was queried for CTPAs ordered for adult patients in the emergency department. We assessed the following patient factors: age, gender, body mass index, number of comorbidities, race, and ethnicity, provider factors: type (resident, fellow, attending, physician assistant) and environment factors: test time of day, season of visit, and crowdedness of the department. Results: A total of 14,782 CTPAs were reviewed, of which 1366 were found to be positive for PE, resulting in an overall CTPA yield of 9.24%. Provider type was not associated with a difference in yield. Testing was less likely to be positive in younger patients, females, those with lower body mass indexes and those identifying as Asian or Hispanic. Testing was also less likely to be positive when ordered during the overnight shift and during the winter and spring seasons. Conclusion: Our study identified several patient and environmental factors associated with low CTPA yield suggesting potential targets for overtesting. Targeting education and clinical decision support to assist providers in these circumstances may meaningfully improve yields

Assessing 2 D-dimer age-adjustment strategies to optimize computed tomographic use in ED evaluation of pulmonary embolism

STUDY OBJECTIVE: Validate the sensitivity and specificity of 2 age adjustment strategies for d-dimer values in identifying patients at risk for pulmonary embolism (PE) compared with traditional D-dimer cutoff value (500 ng/mL) to decrease inappropriate computed tomography pulmonary angiography (CTPA) use. METHODS: This institutional review board-approved, Health Insurance Portability and Accountability Act-compliant retrospective study included all adult emergency department patients evaluated for PE over a 32-month period (1/1/11-8/30/13). Only patients undergoing CTPA and D-dimer testing were included. We used a validated natural language processing algorithm to parse CTPA radiology reports and determine the presence of acute PE. Outcome measures were sensitivity and specificity of 2 age-adjusted D-dimer cutoffs compared with the traditional cutoff. We used chi2 tests with proportional analyses to assess differences in traditional and age-adjusted (agex10 ng/mL) D-dimer cutoffs, adjusting both by decade and by year. RESULTS: A total 3063 patients with suspected PE were evaluated by CTPA during the study period, and 1055 (34%) also received d-dimer testing. The specificity of age-adjusted D-dimer values was similar or higher for each age group studied compared with traditional cutoff, without significantly compromising sensitivity. Overall, had decade age-adjusted cutoffs been used, 37 CTPAs could have been avoided (19.6% of 189 patients aged \u3e60 years with Wells score50 years with Wells scor

Independent evaluation of a simple clinical prediction rule to identify right ventricular dysfunction in patients with shortness of breath

BACKGROUND: Many patients have unexplained persistent dyspnea after negative computed tomographic pulmonary angiography (CTPA). We hypothesized that many of these patients have isolated right ventricular (RV) dysfunction from treatable causes. We previously derived a clinical decision rule (CDR) for predicting RV dysfunction consisting of persistent dyspnea and normal CTPA, finding that 53% of CDR-positive patients had isolated RV dysfunction. Our goal is to validate this previously derived CDR by measuring the prevalence of RV dysfunction and outcomes in dyspneic emergency department patients. METHODS: A secondary analysis of a prospective observational multicenter study that enrolled patients presenting with suspected PE was performed. We included patients with persistent dyspnea, a nonsignificant CTPA, and formal echo performed. Right ventricular dysfunction was defined as RV hypokinesis and/or dilation with or without moderate to severe tricuspid regurgitation. RESULTS: A total of 7940 patients were enrolled. Two thousand six hundred sixteen patients were analyzed after excluding patients without persistent dyspnea and those with a significant finding on CTPA. One hundred ninety eight patients had echocardiography performed as standard care. Of those, 19% (95% confidence interval [CI], 14%-25%) and 33% (95% CI, 25%-42%) exhibited RV dysfunction and isolated RV dysfunction, respectively. Patients with isolated RV dysfunction or overload were more likely than those without RV dysfunction to have a return visit to the emergency department within 45 days for the same complaint (39% vs 18%; 95% CI of the difference, 4%-38%). CONCLUSION: This simple clinical prediction rule predicted a 33% prevalence of isolated RV dysfunction or overload. Patients with isolated RV dysfunction had higher recidivism rates and a trend toward worse outcomes

The Simplified Geneva Score and the Utilization of the D-Dimer and Computerized Tomography for Assessing Pulmonary Embolism

Background. Pulmonary embolism (PE) is clinically suspected in many patients who complain of shortness of breath or chest pain due to its nonspecific nature. The prevalence of PE, however, is low in this population. To assist physicians in diagnostic decision making, several clinical decision rules (CDR) have been developed. The appropriate use of these CDRs has been proven to decrease the need for expensive, time consuming, and invasive diagnostic imaging procedures. In this study, the appropriateness of D-dimer and CT usage was investigated to rule out pulmonary emboli based on the simplified Geneva score. Methods. A retrospective review was performed on 74 patients with a CT scan ordered through a pulmonary embolism (PE) protocol. Using clinical data, the patients were stratified into “unlikely” and “likely” groups for the presence of PE based on the simplification of the revised Geneva score. Scores of 0-2 were graded as “unlikely” and scores of 3 or greater were “likely.” Results. There were 45/74 (60.8%) patients in the “unlikely” group. Of these, 14/45 (31.1%) received a D-dimer; eight were normal and six elevated. Only one patient in the elevated group had evidence of a PE. Of the remaining 31(39.2%) patients in the “unlikely” group that did not receive a D-dimer, only one had a PE. The “likely” group consisted of 29 (39.2%) patients of whom six received a D-dimer. Three patients had a normal D-dimer and three had an elevated level. Neither of these two groups had a PE. Of the remaining 23 (60.8%) in the “likely” group who did not receive a D-dimer, six had a PE. Conclusions. Diagnosing pulmonary emboli using D-dimer levels and CT scans may be aided by clinical decision rules such as the simplified Geneva system. This process may lead to more effective use of medical resources

The impact of an electronic clinical decision support for pulmonary embolism imaging on the efficiency of computed tomography pulmonary angiography utilisation in a resource-limited setting

Background. Pulmonary embolism (PE) is associated with high morbidity and mortality. Effective intervention requires prompt diagnosis. Computed tomography pulmonary angiography (CTPA) is sensitive and specific for PE and is the investigation of choice. Inappropriate CTPA utilisation results in unnecessary high radiation exposure and is costly. State-of-the-art electronic radiology workflow can provide clinical decision support (CDS) for specialised imaging requests, but there has been limited work on the clinical impact of CDS in PE, particularly in resource-constrained environments.Objective. To determine the impact of an electronic CDS for PE on the efficiency of CTPA utilisation in a resource-limited setting.Methods. In preparation, a PE diagnostic algorithm was distributed to hospital clinicians, explaining the combined role of the validated modified Wells score and the quantitative D-dimer test in defining the pre-test probability of PE. Thereafter, an automated, electronic CDS was introduced for all CTPA requests. Total CTPA referrals and the proportion positive for PE were assessed for three study phases: (i) prediagnostic algorithm; (ii) post-algorithm, pre-CDS; and (iii) post-CDS.Results. The proportion of CTPAs positive for PE after CDS implementation was almost double that prior to introduction of the diagnostic algorithm (phase 1 v. 3, 17.4% v. 30.7%; p=0.036), with a correspondingly significant decrease in the proportion of non-positive CTPAs (phases 1 v. 3, 82.6% v. 69.3%; p=0.015) During phases 2 and 3, no CTPAs were requested for patients with a modified Wells score of ≤4 and a documented negative D-dimer, indicating adherence to the algorithm.Conclusion. Implementing an electronic CDS for PE significantly increased the efficiency of CTPA utilisation and significantly decreased the proportion of inappropriate scans

Clinical applications of MRI in the diagnosis of pulmonary embolism

Pulmonary embolism (PE) is a potentially serious medical condition and is the third most common cause of death among cardiovascular diseases. The diagnosis of PE is made with imaging due to its nonspecific clinical signs and symptoms. Historically, pulmonary angiography has been the gold standard until the emergence of computed tomography pulmonary angiography (CTPA), which has now become the go-to modality due to its fast imaging, availability, and high diagnostic accuracy. However, as with pulmonary angiography, CTPA has its drawbacks, such as ionizing radiation and iodinated contrast agents. It is estimated that approximately 20% of patients with suspected PE have a contraindication to this method. The overall aim of this doctoral thesis can be divided into three parts: 1. To evaluate the diagnostic accuracy of our in-house developed MRI protocol for diagnosing acute PE. 2. To explore other areas where this method could be of benefit since it allows for multiple examinations without any risk to the patients. 3. To understand the emergency doctor's decisions regarding imaging requests for suspected PE. Studies 1–3 are based on a native standard SSFP sequence under free breathing and without respiratory or cardiac gating, repeated five times at each anatomical position. This is done to catch/image the vessels at different breathing and cardiac cycles. Study 4 is a retrospective analysis of the protocol used by physicians to order CTPA in the clinical setting. In Study 1, we looked at the one-year outcome of patients who underwent our MRI protocol as the only diagnostic method for suspected PE due to contraindication to CTPA. This study used clinical outcome instead of an imaging modality as the reference. Our results showed that out of 45 patients with a negative MRI result for PE, only one was diagnosed with DVT within three months. In Study 2, we looked at the feasibility of the MRI method for looking at the natural history of acute PE. We examined 18 patients within 36 hours of PE diagnosis with CTPA and then at one week, one, three, and six months. Our results showed that most of the resolution happens within the first few weeks of the treatment. In Study 3, we evaluated the diagnostic accuracy of our in-house developed MRI protocol in reference to CTPA. A total of 243 cases were included, and two radiologists read the MRI exams. Our results showed a sensitivity of 87% and 89% for Readers 1 and 2, specificity of 100% for both, and a kappa value of 0.88. In Study 4, we looked at PE from a clinician's perspective. Therefore, we retrospectively calculated the clinical decision support system (CDSS) points by extracting data from the Electronic Medical Records (EMR) to examine whether the radiology requests were based on a clinical hunch or the available and recommended clinical decision support systems. Our results showed that clinician bypass these CDSS, which unfortunately leads to lower yield. To conclude, this doctoral thesis has shown that our MRI method is a viable option for diagnosing PE in patients with contraindication to CTPA and can also be used in treatment follow-up of these patients. However, insights from study number 4 inthis thesis showed that the diagnosis of PE is complicated, and more research is needed to improve the diagnostic accuracy for these patients

End-tidal carbon dioxide in the diagnosis of acute pulmonary embolism in hospitalized adult patients

Pulmonary embolism (PE) causes 100,000 deaths and contributes to over 4 billion dollars of annual healthcare costs. Acute PE is a diagnostic challenge as symptoms vary widely and are often nonspecific. Definitive diagnosis requires costly confirmatory testing with computed tomography pulmonary angiogram (CTPA). CTPA risks include allergic reactions, contrast-induced nephropathy and radiation exposure. The purpose of this study is two-fold: 1) to examine the accuracy, financial impact, and harm avoidance of adding EtCO[2] to the PE diagnostic process and 2) to evaluate clinician adherence to national guidelines (BPA) for PE diagnosis. A single center prospective, descriptive, correlational design comparing EtCO[2] values to CTPA results. Medical records were reviewed to determine BPA adherence. A total of 111 patients had definitive CT results. Mean ([plus or minus]SD) EtCO[2] was higher for PE+ (28[plus or minus]7.8) versus PE- (33[plus or minus] 8.1) patients (p =.01). For PE exclusion, an EtCO[2] cutoff value of [greater than or equal to]42mmHg yielded a sensitivity of 100%, specificity of 12.2% and a negative predictive value of 100% and could safely eliminate 11 patients (9.9%) from receiving CTPA. For every 6 patients assessed with EtCO[2], one can be saved from CTPA. Overall BPA adherence was 0%. Partial adherence was observed with clinician recorded clinical decisions rules in 3.6% (4/111) and D-dimer was obtained in 10.2% (9/88). EtCO[2] cutoff value of [greater than or equal to]42mmHg could decrease CTPA scans use in [about]10% of adult inpatients suspected of PE eliminating exposure to CTPA risks. Lack of clinical decision support may contribute to low BPA compliance.Includes bibliographical reference

Examining clinical decision support integrity: is clinician self-reported data entry accurate?

The aim of this study was to assess the accuracy of clinician-entered data in imaging clinical decision support (CDS). We used CDS-guided CT angiography (CTA) for pulmonary embolus (PE) in the emergency department as a case example because it required clinician entry of d-dimer results which could be unambiguously compared with actual laboratory values. Of 1296 patients with CTA orders for suspected PE during 2011, 1175 (90.7%) had accurate d-dimer values entered. In 55 orders (4.2%), incorrectly entered data shielded clinicians from intrusive computer alerts, resulting in potential CTA overuse. Remaining data entry errors did not affect user workflow. We found no missed PEs in our cohort. The majority of data entered by clinicians into imaging CDS are accurate. A small proportion may be intentionally erroneous to avoid intrusive computer alerts. Quality improvement methods, including academic detailing and improved integration between electronic medical record and CDS to minimize redundant data entry, may be necessary to optimize adoption of evidence presented through CDS

THE HIGH COST OF LOW VALUE CARE

The main focus of this study is bridging the evidence gap between frontline decision-making in health care and the actual evidence, with the hope of reducing unnecessary diagnostic testing and treatments. From our work in pulmonary embolism (PE) and over ordering of computed tomography pulmonary angiography, we integrated the highly validated Wells\u27 criteria into the electronic health record at two of our major academic tertiary hospitals. The Wells\u27 clinical decision support tool triggered for patients being evaluated for PE and therefore determined a patients\u27 pretest probability for having a PE. There were 12,759 patient visits representing 11,836 patients, 51% had no D-dimer, 41% had a negative D-dimer, and 9% had a positive D-dimer. Our study gave us an opportunity to determine which patients were very low probabilities for PE, with no need for further testing