USE OF COMPUTED TOMOGRAPHIC PULMONARY ANGIOGRAPHY FOR THE DIAGNOSIS OF PULMONARY EMBOLISM; ARE WE OVERDOING IT?
Abstract
Background: Computed tomographic pulmonary angiography (CTPA) is a gold standard test for the diagnosis of pulmonary embolism (PE), but is reported to be over prescribed. We performed this study to determine over prescription of CTPAs at a District General Hospital (DGH) in the United Kingdom. Our secondary aim was to establish a cause of its over-prescription. Methods: We retrospectively reviewed clinical data of all patients who underwent CTPAs during January 2011 to July 2013. Collected data included CTPA findings, clinical probability score, D-dimer results, chest x-ray (CXR) findings and patient’s demographic data. A calculation of overall clinical probability (including initial and post CTPA values) and its cross analysis with D-dimer, CTPA and CXR findings was made. Results: Pulmonary embolism was positive in 5 (11.6%) cases. An Initial probability score was available in 16 (37.20%), and a D-dimer result was available in 33 (76.7%). Chest X-ray (CXR) was abnormal in 8 (18.6%). A coupling of total probability score with D-dimer results (CPPD) identified 10 (22.2%) potential over prescriptions. A further analysis of CPPD with CXR revealed a definite over prescription of 8 (18.6%), whereas it increased the number of an overall possible over prescription to 14 (32.6%). Conclusion: The CTPAs are being over prescribed and the main reasons behind it are poor utilization of probability scoring systems, D-dimer rule and lack of interpretation of alternative diagnosis on CXRs.Keywords: Pulmonary Embolism, Tomography, X-Ray Computed, Probability, fibrin fragment D, PrescriptionsReferences
PIOPED. Investigators. Value of the ventilation/perfusion scan in acute pulmonary embolism: results of the prospective Investigation of Pulmonary Embolism Diagnostic (PIOPED). JAMA 1990;263:2753–9.
Lee AY, Hirsh J. Diagnosis and treatment of venous thromboembolism. Annu Rev Med 2002;53:15–33.
Wells PS, Anderson DR, Rodger M, Ginsberg JS, Kearon C, Gent M, et al. Derivation of a simple clinical model to categorize patient’s probability of pulmonary embolism; increasing the models utility with the simplified D-dimer. Thromb Haemost 2000;83:416–20.
O'Neill JM, Wright L, Murchison JT. Helical CTPA in the investigation of pulmonary embolism: a 6-year review. Clin Radiol 2004;59:819–25.
Einstein AJ, Henzlova MJ, Rajagopalan S. Estimating risk of cancer associated with radiation exposure from 64-slice computed tomography coronary angiography. JAMA 2007;298:317–23.
Mitchell AM, Kline JA. Contrast nephropathy following computed tomography angiography of the chest for pulmonary embolism in the emergency department. J Thromb Haemost 2007;5:50–4.
Le Gal G, Righini M, Parent F, van Strijen M, Couturaud F. Diagnosis and management of subsegmental pulmonary embolism. J Thromb. Haemost 2006;4:724–31.
Davies HE, Wathen CG, Gleeson FV. Risks of exposure to radiological imaging and how to minimise them. BMJ 2011;342:589–93.
van Belle A, Büller HR, Huisman MV, Huisman PM, Kaasjager K, Kamphuisen PW, et al. Writing Group for the Christopher Study Investigators. Effectiveness of managing pulmonary embolism using an algorithm combining clinical probability, D-dimers testing and Computed Tomography. JAMA 2006;295:172–9.
Klok FA, Mos IC, Nijkeuter M, Righini M, Perrier A, Le Gal G, et al. Simplification of the revised Geneva score for assessing clinical probability of pulmonary embolism. Arch Intern Med 2008;168:2131–6.
Lucassen W, Geersing GJ, Erkens PM, Reitsma JB, Moons KG, Buller H, et al. Clinical decision rules for excluding pulmonary embolism: a meta-analysis. Ann intern Med 2011;155:448–60.
Greesing GJ, Erkens PM, Lucassen WA, Buller HR, Cate HT, Hoes AW, et al. Safe exclusion of pulmonary embolism using wells rule and qualitative D-dimer testing in primary care: a prospective cohort study. BMJ 2012:345:e6564.
O'Connor C, Moriarty J, Walsh J, Murray J, Coulter-Smith S, Boyd W. The application of a clinical risk stratification score may reduce unnecessary investigations for pulmonary embolism in pregnancy. J Matern Fetal Neonatal Med 2011;24:1461–4.
Ng BJ, Lindstrom S. Study of compliance with a clinical pathway for suspected pulmonary embolism. Intern Med J 2011;41(3):251–7.
Published
Issue
Section
License
Journal of Ayub Medical College, Abbottabad is an OPEN ACCESS JOURNAL which means that all content is FREELY available without charge to all users whether registered with the journal or not. The work published by J Ayub Med Coll Abbottabad is licensed and distributed under the creative commons License CC BY ND Attribution-NoDerivs. Material printed in this journal is OPEN to access, and are FREE for use in academic and research work with proper citation. J Ayub Med Coll Abbottabad accepts only original material for publication with the understanding that except for abstracts, no part of the data has been published or will be submitted for publication elsewhere before appearing in J Ayub Med Coll Abbottabad. The Editorial Board of J Ayub Med Coll Abbottabad makes every effort to ensure the accuracy and authenticity of material printed in J Ayub Med Coll Abbottabad. However, conclusions and statements expressed are views of the authors and do not reflect the opinion/policy of J Ayub Med Coll Abbottabad or the Editorial Board.
USERS are allowed to read, download, copy, distribute, print, search, or link to the full texts of the articles, or use them for any other lawful purpose, without asking prior permission from the publisher or the author. This is in accordance with the BOAI definition of open access.
AUTHORS retain the rights of free downloading/unlimited e-print of full text and sharing/disseminating the article without any restriction, by any means including twitter, scholarly collaboration networks such as ResearchGate, Academia.eu, and social media sites such as Twitter, LinkedIn, Google Scholar and any other professional or academic networking site.
