D-dimer tests and prediction rules should be incorporated into a decision support tool to curb overordering of CTPA for suspected pulmonary embolism.
Computed tomography pulmonary angiography (CTPA) for the diagnosis of pulmonary embolism (PE) in the emergency department is most often ordered by emergency medicine providers, according to a study published in the Journal of the American College of Radiology.
Researchers from NYU Langone Medical Center in New York City sought to better understand the decision-making behind the ordering of CTPA for the diagnosis of PE in the emergency department.
Using semistructured interviews with emergency medicine (EM) providers and radiologists who read CTPAs performed in the emergency department, the researchers employed the Theoretical Domains Framework. This is a formal, structured approach used to better understand the motivations and beliefs of physicians surrounding a complex medical decision-making. The themes were then categorized.
The results showed that EM providers most often ordered CTPA. Both EM and radiologist groups perceived the radiologist’s role as more limited. Experience- and gestalt-based heuristics were the most important factors driving this decision and more important, in many cases, than established algorithms for CTPA ordering. The researchers noted there were contrasting views on the value of d-dimer in the suspected PE workup, with EM providers finding this test less useful than radiologists. EM provider and radiologist suggestions for improving the appropriateness of CTPA ordering consisted of making this process more arduous and incorporating d-dimer tests and prediction rules into a decision support tool.
The researchers concluded that EM providers were the main drivers of CTPA ordering, and there was a marginalized role for the radiologist. They wrote that their findings suggested that a more nuanced intervention than simply including a d-dimer and a prediction score in each preimaging workup may be necessary to curb overordering of CTPA in patients suspected of PE.