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- Title
Ordering CT pulmonary angiography to exclude pulmonary embolism: defense versus evidence in the emergency room.
- Authors
Rohacek, Martin; Buatsi, Janet; Szucs-Farkas, Zsolt; Kleim, Birgit; Zimmermann, Heinz; Exadaktylos, Aristomenis; Stoupis, Christoforos
- Abstract
Purpose: To identify reasons for ordering computed tomography pulmonary angiography (CTPA), to identify the frequency of reasons for CTPA reflecting defensive behavior and evidence-based behavior, and to identify the impact of defensive medicine and of training about diagnosing pulmonary embolism (PE) on positive results of CTPA. Methods: Physicians in the emergency department of a tertiary care hospital completed a questionnaire before CTPA after being trained about diagnosing PE and completing questionnaires. Results: Nine hundred patients received a CTPA during 3 years. For 328 CTPAs performed during the 1-year study period, 140 (43 %) questionnaires were completed. The most frequent reasons for ordering a CTPA were to confirm/rule out PE (93 %), elevated D-dimers (66 %), fear of missing PE (55 %), and Wells/simplified revised Geneva score (53 %). A positive answer for 'fear of missing PE' was inversely associated with positive CTPA (OR 0.36, 95 % CI 0.14-0.92, p = 0.033), and 'Wells/simplified revised Geneva score' was associated with positive CTPA (OR 3.28, 95 % CI 1.24-8.68, p = 0.017). The proportion of positive CTPA was higher if a questionnaire was completed, compared to the 2-year comparison period (26.4 vs. 14.5 %, OR 2.12, 95 % CI 1.36-3.29, p < 0.001). The proportion of positive CTPA was non-significantly higher during the study period than during the comparison period (19.2 vs. 14.5 %, OR 1.40, 95 % CI 0.98-2.0, p = 0.067). Conclusion: Reasons for CTPA reflecting defensive behavior-such as 'fear of missing PE'-were frequent, and were associated with a decreased odds of positive CTPA. Defensive behavior might be modifiable by training in using guidelines.
- Subjects
PULMONARY embolism; PNEUMOANGIOGRAPHY; PULMONARY artery diseases; DEFENSIVE medicine; EMERGENCY physicians; DIAGNOSIS
- Publication
Intensive Care Medicine, 2012, Vol 38, Issue 8, p1345
- ISSN
0342-4642
- Publication type
Article
- DOI
10.1007/s00134-012-2595-z