Big-Picture Solutions to Over-Investigating
Some potential solutions to over-investigating include malpractice reform, more time spent talking to patients, and a change in the system of financial rewards for ordering tests. For PE workup in particular, departmental decision support systems have been shown to reduce imaging rates and increase diagnostic yield.17
Explore This IssueACEP Now: Vol 38 – No 03 – March 2019
So next time you’re about to pull the trigger on ordering a CTPA for suspected PE based on gestalt, instead take the time to use your evidence-based departmental decision support system that utilizes diagnostic decision tools such as Geneva score, Wells’ score, D-dimer and PERC rule. If your patient is young or has a contrast allergy, consider a V/Q SPECT as a potentially more accurate test for PE that may result in fewer false positives with less radiation than CTPA.
Special thanks to Dr. Eddy Lang and Dr. Kerstin de Wit for their expert contributions to the EM Cases podcast on which this article was based.
- Pollack CV, Schreiber D, Goldhaber SZ, et al. Clinical characteristics, management, and outcomes of patients diagnosed with acute pulmonary embolism in the emergency department: initial report of EMPEROR (Multicenter Emergency Medicine Pulmonary Embolism in the Real World Registry). J Am Coll Cardiol. 2011;57(6):700-706.
- Bariteau A, Stewart LK, Emmett TW, et al. Systematic review and meta-analysis of outcomes of patients with subsegmental pulmonary embolism with and without anticoagulation treatment. Acad Emerg Med. 2018;25(7):828-835.
- MacDougall DA, Feliu AL, Boccuzzi SJ, et al. Economic burden of deep-vein thrombosis, pulmonary embolism, and post-thrombotic syndrome. Am J Health Syst Pharm. 2006;63(20 suppl 6):S5-S15.
- Schechter MT, Sheps SB. Diagnostic testing revisited: pathways through uncertainty. Can Med Assoc J. 1985;132(7):755-760.
- Penaloza A, Verschuren F, Meyer G, et al. Comparison of the unstructured clinician gestalt, the wells score, and the revised Geneva score to estimate pretest probability for suspected pulmonary embolism. Ann Emerg Med. 2013;62(2):117-124.e2.
- Freund Y, Cachanado M, Aubry A, et al. Effect of the pulmonary embolism rule-out criteria on subsequent thromboembolic events among low-risk emergency department patients: the PROPER randomized clinical trial. JAMA. 2018;319(6):559-566.
- Kline JA, Stubblefield WB. Clinician gestalt estimate of pretest probability for acute coronary syndrome and pulmonary embolism in patients with chest pain and dyspnea. Ann Emerg Med. 2014;63(3):275-280.
- van Belle A, Büller HR, Huisman MV, et al. Effectiveness of managing suspected pulmonary embolism using an algorithm combining clinical probability, D-dimer testing, and computed tomography. JAMA. 2006;295(2):172-179.
- van der Hulle T, van Es N, den Exter PL, et al. Is a normal computed tomography pulmonary angiography safe to rule out acute pulmonary embolism in patients with a likely clinical probability? A patient-level meta-analysis. Thromb Haemost. 2017;117(8):1622-1629.
- Belzile D, Jacquet S, Bertoletti L, et al. Outcomes following a negative computed tomography pulmonary angiography according to pulmonary embolism prevalence: a meta-analysis of the management outcome studies. J Thromb Haemost. 2018;16(6):1107-1120.
- den Exter PL, van Es J, Klok FA, et al. Risk profile and clinical outcome of symptomatic subsegmental acute pulmonary embolism. Blood. 2013;122(7):1144-1149.
- Gutte H, Mortensen J, Jensen CV, et al. Comparison of V/Q SPECT and planar V/Q lung scintigraphy in diagnosing acute pulmonary embolism. Nucl Med Commun. 2010;31(1):82-86.
- Bhatia KD, Ambati C, Dhaliwal R, et al. SPECT-CT/VQ versus CTPA for diagnosing pulmonary embolus and other lung pathology: pre-existing lung disease should not be a contraindication. J Med Imaging Radiat Oncol. 2016;60(4):492-497.
- Goy J, Lee J, Levine O, et al. Sub-segmental pulmonary embolism in three academic teaching hospitals: a review of management and outcomes. J Thromb Haemost. 2015;13(2):214-218.
- Yoo HH, Queluz TH, El Dib R. Anticoagulant treatment for subsegmental pulmonary embolism. Cochrane Database Syst Rev. 2014;(4):CD010222.
- ACEP Clinical Policies Subcommittee (Writing Committee) on Thromboembolic Disease. Clinical policy: critical issues in the evaluation and management of adult patients presenting to the emergency department with suspected acute venous thromboembolic disease. Ann Emerg Med. 2018;71(5):e59-109.
- Deblois S, Chartrand-Lefebvre C, Toporowicz K, et al. Interventions to reduce the overuse of imaging for pulmonary embolism: a systematic review. J Hosp Med. 2018;13(1):52-61.