Leila Salehi1,2,3, Prashant Phalpher4,5, Hubert Yu6, Jeffrey Jaskolka7, Marc Ossip7, Christopher Meaney4, Rahim Valani5,8, Mathew Mercuri8. 1. Department of Family Medicine, McMaster University, 100 Main Street West, 6th floor, Hamilton, Ontario, Canada. Leila.salehi@utoronto.ca. 2. Department of Family and Community Medicine, University of Toronto, 500 University Avenue, Toronto, Ontario, Canada. Leila.salehi@utoronto.ca. 3. Department of Emergency Medicine, William Osler Health System, Suite S.1.184, 2100 Bovaird Avenue East, Brampton, Ontario, Canada. Leila.salehi@utoronto.ca. 4. Department of Family Medicine, McMaster University, 100 Main Street West, 6th floor, Hamilton, Ontario, Canada. 5. Department of Emergency Medicine, William Osler Health System, Suite S.1.184, 2100 Bovaird Avenue East, Brampton, Ontario, Canada. 6. Department of Family and Community Medicine, University of Toronto, 500 University Avenue, Toronto, Ontario, Canada. 7. Department of Diagnostic Imaging, William Osler Health System, 2100 Bovaird Avenue East, Brampton, Ontario, Canada. 8. Division of Emergency Medicine, McMaster University, Hamilton Health Sciences, McMaster Clinic, 2nd floor, 237 Barton Street East, Hamilton, Ontario, Canada.
Abstract
BACKGROUND: A variety of evidence-based algorithms and decision rules using D-Dimer testing have been proposed as instruments to allow physicians to safely rule out a pulmonary embolism (PE) in low-risk patients. OBJECTIVE: To describe the prevalence of D-Dimer utilization among emergency department (ED) physicians and its impact on positive yields and utilization rates of Computed Tomography Pulmonary Angiography (CTPA). METHODS: Data was collected on all CTPA studies ordered by ED physicians at three sites during a 2-year period. Using a chi-square test, we compared the diagnostic yield for those patients who had a D-Dimer prior to their CTPA and those who did not. Secondary analysis was done to examine the impact of D-Dimer testing prior to CTPA on individual physician diagnostic yield or utilization rate. RESULTS: A total of 2811 CTPAs were included in the analysis. Of these, 964 CTPAs (34.3%) were ordered without a D-Dimer, and 343 (18.7%) underwent a CTPA despite a negative D-Dimer. Those CTPAs preceded by a D-Dimer showed no significant difference in positive yields when compared to those ordered without a D-Dimer (9.9% versus 11.3%, p = 0.26). At the individual physician level, no statistically significant relationship was found between D-Dimer utilization and CTPA utilization rate or diagnostic yield. CONCLUSION: This study provides evidence of suboptimal adherence to guidelines in terms of D-Dimer screening prior to CTPA, and forgoing CTPAs in patients with negative D-Dimers. However, the lack of a positive impact of D-Dimer testing on either CTPA diagnostic yield or utilization rate is indicative of issues relating to the high false-positive rates associated with D-Dimer screening.
BACKGROUND: A variety of evidence-based algorithms and decision rules using D-Dimer testing have been proposed as instruments to allow physicians to safely rule out a pulmonary embolism (PE) in low-risk patients. OBJECTIVE: To describe the prevalence of D-Dimer utilization among emergency department (ED) physicians and its impact on positive yields and utilization rates of Computed Tomography Pulmonary Angiography (CTPA). METHODS: Data was collected on all CTPA studies ordered by ED physicians at three sites during a 2-year period. Using a chi-square test, we compared the diagnostic yield for those patients who had a D-Dimer prior to their CTPA and those who did not. Secondary analysis was done to examine the impact of D-Dimer testing prior to CTPA on individual physician diagnostic yield or utilization rate. RESULTS: A total of 2811 CTPAs were included in the analysis. Of these, 964 CTPAs (34.3%) were ordered without a D-Dimer, and 343 (18.7%) underwent a CTPA despite a negative D-Dimer. Those CTPAs preceded by a D-Dimer showed no significant difference in positive yields when compared to those ordered without a D-Dimer (9.9% versus 11.3%, p = 0.26). At the individual physician level, no statistically significant relationship was found between D-Dimer utilization and CTPA utilization rate or diagnostic yield. CONCLUSION: This study provides evidence of suboptimal adherence to guidelines in terms of D-Dimer screening prior to CTPA, and forgoing CTPAs in patients with negative D-Dimers. However, the lack of a positive impact of D-Dimer testing on either CTPA diagnostic yield or utilization rate is indicative of issues relating to the high false-positive rates associated with D-Dimer screening.
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