Emma Simon1, Isomi M Miake-Lye2, Silas W Smith3, Jordan L Swartz4, Leora I Horwitz5, Danil V Makarov6, Soterios Gyftopoulos7. 1. Department of Population Health, NYU School of Medicine, New York, New York; Center for Healthcare Innovation and Delivery Science, NYU School of Medicine, New York, New York. Electronic address: emma.simon@nyumc.org. 2. Center for Healthcare Innovation and Delivery Science, NYU School of Medicine, New York, New York; VA Greater Los Angeles Healthcare System, Los Angeles, California. 3. Ronald O. Perelman Department of Emergency Medicine, NYU School of Medicine, New York, New York; Institute for Innovations in Medical Education, NYU School of Medicine, New York, New York. 4. Ronald O. Perelman Department of Emergency Medicine, NYU School of Medicine, New York, New York. 5. Department of Population Health, NYU School of Medicine, New York, New York; Center for Healthcare Innovation and Delivery Science, NYU School of Medicine, New York, New York; Department of Medicine, NYU School of Medicine, New York, New York. 6. Department of Population Health, NYU School of Medicine, New York, New York; Department of Urology, NYU School of Medicine, New York, New York; VA New York Harbor Healthcare System, NYU School of Medicine, New York, New York. 7. Department of Radiology, NYU School of Medicine, New York, New York; Department of Orthopedic Surgery, NYU School of Medicine, New York, New York.
Abstract
PURPOSE: The aim of this study was to determine rates of and possible reasons for guideline-discordant ordering of CT pulmonary angiography for the evaluation of suspected pulmonary embolism (PE) in the emergency department. METHODS: A retrospective review was performed of 212 consecutive encounters (January 6, 2016, to February 25, 2016) with 208 unique patients in the emergency department that resulted in CT pulmonary angiography orders. For each encounter, the revised Geneva score and two versions of the Wells criteria were calculated. Each encounter was then classified using a two-tiered risk stratification method (PE unlikely versus PE likely). Finally, the rate of and possible explanations for guideline-discordant ordering were assessed via in-depth chart review. RESULTS: The frequency of guideline-discordant studies ranged from 53 (25%) to 79 (37%), depending on the scoring system used; 46 (22%) of which were guideline discordant under all three scoring systems. Of these, 18 (39%) had at least one patient-specific factor associated with increased risk for PE but not included in the risk stratification scores (eg, travel, thrombophilia). CONCLUSIONS: Many of the guideline-discordant orders were placed for patients who presented with evidence-based risk factors for PE that are not included in the risk stratification scores. Therefore, guideline-discordant ordering may indicate that in the presence of these factors, the assessment of risk made by current scoring systems may not align with clinical suspicion.
PURPOSE: The aim of this study was to determine rates of and possible reasons for guideline-discordant ordering of CT pulmonary angiography for the evaluation of suspected pulmonary embolism (PE) in the emergency department. METHODS: A retrospective review was performed of 212 consecutive encounters (January 6, 2016, to February 25, 2016) with 208 unique patients in the emergency department that resulted in CT pulmonary angiography orders. For each encounter, the revised Geneva score and two versions of the Wells criteria were calculated. Each encounter was then classified using a two-tiered risk stratification method (PE unlikely versus PE likely). Finally, the rate of and possible explanations for guideline-discordant ordering were assessed via in-depth chart review. RESULTS: The frequency of guideline-discordant studies ranged from 53 (25%) to 79 (37%), depending on the scoring system used; 46 (22%) of which were guideline discordant under all three scoring systems. Of these, 18 (39%) had at least one patient-specific factor associated with increased risk for PE but not included in the risk stratification scores (eg, travel, thrombophilia). CONCLUSIONS: Many of the guideline-discordant orders were placed for patients who presented with evidence-based risk factors for PE that are not included in the risk stratification scores. Therefore, guideline-discordant ordering may indicate that in the presence of these factors, the assessment of risk made by current scoring systems may not align with clinical suspicion.
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