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Aggarwal T, Eskandari A, Priya S, Mullan A, Garg I, Siembida J, Mullan B, Nagpal P. Pulmonary embolism rule out: positivity and factors affecting the yield of CT angiography. Postgrad Med J 2020; 96:594-599. [PMID: 31907225 DOI: 10.1136/postgradmedj-2019-137031] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Revised: 11/22/2019] [Accepted: 12/09/2019] [Indexed: 12/18/2022]
Abstract
OBJECTIVE CT pulmonary angiography (CTPA) is one of the most commonly ordered CT imaging tests. It is often believed to be overutilised with few recent studies showing a yield of less than 2%. This study aimed to determine the overall positivity rate of CTPA examinations and understand the factors that affect the yield of the CTPA examination. METHODS We retrospectively analysed 2713 patients who received the CTPA exam between 2016 and 2018. Type of study ordered (CTPA chest or CTPA chest with abdomen and pelvis CT), patient location (emergency department (ED), outpatient, inpatient, intensive care unit (ICU)) and patient characteristics-age, sex and body mass index (BMI) were recorded. A logistic regression analysis was performed to determine what factors affect the positivity rate of CT scans for pulmonary embolism (PE). RESULTS With 296 positive test results, the overall CTPA positivity was 10.9%. Male sex was associated with higher CTPA positivity, gender difference was maximum in 18-year to 35-year age group. Overweight and obese patients had significantly higher positivity as compared with BMI<25 (p<0.05). Higher positivity rate was seen in the BMI 25-40 group (11.9%) as compared with BMI>40 (10.1%) (p<0.05). Significant difference (p<0.001) was also found in CTPA examination yield from ICU (15.3%) versus inpatients (other than ICU) (12.4%) versus ED (9.6%), and outpatients (8.5%). The difference in CTPA yield based on the type of CT order (CTPA chest vs CTPA chest with CT abdomen and pelvis), patient's age and sex was not significant. CONCLUSION CTPA yield of 10.9% in this study is comparable to acceptable positivity rate for the USA and is higher than recent studies showing positivity of <2%. Patient characteristics like obesity and ICU or inpatient location are associated with higher rate of CT positivity.
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Affiliation(s)
- Tanya Aggarwal
- Department of Radiology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Ali Eskandari
- Department of Radiology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Sarv Priya
- Department of Radiology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Aidan Mullan
- Statistics, University of California Berkeley, Berkeley, California, USA
| | - Ishan Garg
- Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Jakub Siembida
- Department of Radiology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Brian Mullan
- Department of Radiology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Prashant Nagpal
- Department of Radiology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
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Osman M, Subedi SK, Ahmed A, Khan J, Dawood T, Ríos-Bedoya CF, Bachuwa G. Computed tomography pulmonary angiography is overused to diagnose pulmonary embolism in the emergency department of academic community hospital. J Community Hosp Intern Med Perspect 2018; 8:6-10. [PMID: 29441158 PMCID: PMC5804676 DOI: 10.1080/20009666.2018.1428024] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Accepted: 01/11/2018] [Indexed: 12/02/2022] Open
Abstract
Background: Pulmonary embolism (PE) is a common disease in the USA responsible for up to 10% of hospital mortality. Modified wells score (MWS) and D-dimer assay are used to categorize patients into high or low probability of PE. Patient with high probability need Computed tomography pulmonary angiography (CTPA), while patients with low probability and low D-dimer can safely forgo the CTPA. Objectives: The aim of this study was to investigate the rate of inappropriate CTPA use in the emergency department of a community teaching hospital. Methods: A retrospective chart review of adult patients who underwent CTPA for suspected PE in the emergency department for 2015 was done. CTPA use was considered inappropriate if MWS was less than or equal to 4 and D-dimer was either not ordered or its value was less than 500 μg/L. Bivariate analysis with Fisher’s exact tests and Student’s t-tests as well as multivariate logistic regression analysis were done to examine relationship between study explanatory variables and study outcome. Results: 295 patients were included in the study. The mean age was 51.2(±14.5) years, 68.8% were females. The prevalence of PE was 5.4% and 41% of the CTPAs -were inappropriately ordered. Males were twice (OR 2.1; 95% CI 1.2, 3.6) as likely as females to have an inappropriately ordered CTPA after controlling for a high MWS, age, and tobacco history. Conclusion: CTPA is overused to diagnose PE in the emergency department. Quality improvement projects are needed to encourage physicians to adhere to the current guidelines.
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Affiliation(s)
- Mohammed Osman
- Department of Medicine, Hurley Medical Center, Michigan State University, Flint, MI, USA
| | - Suresh Kumar Subedi
- Department of Medicine, Hurley Medical Center, Michigan State University, Flint, MI, USA
| | - Azza Ahmed
- Department of Medicine, Hurley Medical Center, Michigan State University, Flint, MI, USA
| | - Jahangir Khan
- Department of Medicine, Hurley Medical Center, Michigan State University, Flint, MI, USA
| | - Thair Dawood
- Department of Medicine, Hurley Medical Center, Michigan State University, Flint, MI, USA
| | - Carlos F Ríos-Bedoya
- Department of Medicine, Hurley Medical Center, Michigan State University, Flint, MI, USA
| | - Ghassan Bachuwa
- Department of Medicine, Hurley Medical Center, Michigan State University, Flint, MI, USA
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Alhassan S, Sayf AA, Arsene C, Krayem H. Suboptimal implementation of diagnostic algorithms and overuse of computed tomography-pulmonary angiography in patients with suspected pulmonary embolism. Ann Thorac Med 2016; 11:254-260. [PMID: 27803751 PMCID: PMC5070434 DOI: 10.4103/1817-1737.191875] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2016] [Accepted: 07/14/2016] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Majority of our computed tomography-pulmonary angiography (CTPA) scans report negative findings. We hypothesized that suboptimal reliance on diagnostic algorithms contributes to apparent overuse of this test. METHODS A retrospective review was performed on 2031 CTPA cases in a large hospital system. Investigators retrospectively calculated pretest probability (PTP). Use of CTPA was considered as inappropriate when it was ordered for patients with low PTP without checking D-dimer (DD) or following negative DD. RESULTS Among the 2031 cases, pulmonary embolism (PE) was found in 7.4% (151 cases). About 1784 patients (88%) were considered "PE unlikely" based on Wells score. Out of those patients, 1084 cases (61%) did not have DD test prior to CTPA. In addition, 78 patients with negative DD underwent unnecessary CTPA; none of them had PE. CONCLUSIONS The suboptimal implementation of PTP assessment tools can result in the overuse of CTPA, contributing to ineffective utilization of hospital resources, increased cost, and potential harm to patients.
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Affiliation(s)
- Sulaiman Alhassan
- Department of Medicine, Detroit Medical Center, Wayne State University, Detroit, Michigan, USA
| | - Alaa Abu Sayf
- Department of Medicine, Detroit Medical Center, Wayne State University, Detroit, Michigan, USA
| | - Camelia Arsene
- Department of Medicine, Detroit Medical Center, Wayne State University, Detroit, Michigan, USA
| | - Hicham Krayem
- Division of Pulmonary and Critical Care Medicine, Detroit Medical Center, Wayne State University, Detroit, Michigan, USA
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Doganay S, Oguz AK, Ergun I. Increased risk of contrast-induced acute kidney injury in patients with pulmonary thromboembolism. Ren Fail 2015; 37:1138-44. [PMID: 26139228 DOI: 10.3109/0886022x.2015.1061869] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Computed tomography pulmonary angiography (CTPA) is currently an effective, reliable and widely employed diagnostic test for pulmonary thromboembolism (PT). PT harbors intrinsic clinical and biochemical abnormalities which may be associated with an increased risk of contrast-induced acute kidney injury (CIAKI). OBJECTIVES To assess the incidence and risk factors of CIAKI among patients with PT diagnosed with CTPA. METHODS One hundred and twenty-two consecutive patients who had been diagnosed with PT using CTPA between February 2006 and December 2010 were evaluated retrospectively. In addition to the classical risk factors of CIAKI, arterial blood gases, CTPA and transthoracic echocardiography findings of the patients were also recorded. RESULTS The incidence of CIAKI was 13.1%. There were statistically important differences with respect to age, the presence of congestive heart failure (CHF), the use of angiotensin converting enzyme inhibitor-angiotensin II receptor blocker drugs (ACEI-ARB), the arterial blood pH (ABpH) and the length of hospitalization between the two groups of patients who developed (n:16) and did not develop (n:106) CIAKI. In the logistic regression analysis, age and ABpH were preserved in the final equation. CONCLUSION The incidence of CIAKI among PT patients is significantly higher than the expected average. Older age, the presence of CHF, the use of ACEI-ARB, and additionally, low ABpH are important risk factors of CIAKI in patients with PT. Hypoxemia and low bicarbonate levels intrinsic to PT may contribute to the increased risk of CIAKI in this patient population and their correction may carry a prophylactic potential.
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Affiliation(s)
| | - Ali Kemal Oguz
- b Department of Internal Medicine , Ufuk University School of Medicine , Ankara , Turkey , and
| | - Ihsan Ergun
- c Division of Nephrology , Department of Internal Medicine, Ufuk University School of Medicine , Ankara , Turkey
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Nazerian P, Vanni S, Volpicelli G, Gigli C, Zanobetti M, Bartolucci M, Ciavattone A, Lamorte A, Veltri A, Fabbri A, Grifoni S. Accuracy of point-of-care multiorgan ultrasonography for the diagnosis of pulmonary embolism. Chest 2014; 145:950-957. [PMID: 24092475 DOI: 10.1378/chest.13-1087] [Citation(s) in RCA: 150] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Presenting signs and symptoms of pulmonary embolism (PE) are nonspecific, favoring a large use of second-line diagnostic tests such as multidetector CT pulmonary angiography (MCTPA), thus exposing patients to high-dose radiation and to potential serious complications. We investigated the diagnostic performance of multiorgan ultrasonography (lung, heart, and leg vein ultrasonography) and whether multiorgan ultrasonography combined to Wells score and D-dimer could safely reduce MCTPA tests. METHODS Consecutive adult patients suspected of PE and with a Wells score > 4 or a positive D-dimer result were prospectively enrolled in three EDs. Final diagnosis was obtained with MCTPA. Multiorgan ultrasonography was performed before MCTPA and considered diagnostic for PE if one or more subpleural infarcts, right ventricular dilatation, or DVT was detected. If multiorgan ultrasonography was negative for PE, an alternative ultrasonography diagnosis was sought. Accuracies of each single-organ and multiorgan ultrasonography were calculated. RESULTS PE was diagnosed in 110 of 357 enrolled patients (30.8%). Multiorgan ultrasonography yielded a sensitivity of 90% and a specificity of 86.2%, lung ultrasonography 60.9% and 95.9%, heart ultrasonography 32.7% and 90.9%, and vein ultrasonography 52.7% and 97.6%, respectively. Among the 132 patients (37%) with multiorgan ultrasonography negative for PE plus an alternative ultrasonographic diagnosis or plus a negative D-dimer result, no patients received PE as a final diagnosis. CONCLUSIONS Multiorgan ultrasonography is more sensitive than single-organ ultrasonography, increases the accuracy of clinical pretest probability estimation in patients with suspected PE, and may safely reduce the MCTPA burden. TRIAL REGISTRY ClinicalTrials.gov; No.: NCT01635257; URL: www.clinicaltrials.gov.
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Affiliation(s)
- Peiman Nazerian
- Department of Emergency Medicine, Careggi University Hospital, Firenze.
| | - Simone Vanni
- Department of Emergency Medicine, Careggi University Hospital, Firenze
| | - Giovanni Volpicelli
- Department of Emergency Medicine, San Luigi Gonzaga University Hospital, Torino
| | - Chiara Gigli
- Department of Emergency Medicine, Careggi University Hospital, Firenze
| | | | | | | | - Alessandro Lamorte
- Department of Emergency Medicine, San Luigi Gonzaga University Hospital, Torino
| | - Andrea Veltri
- Radiology Department, San Luigi Gonzaga University Hospital, Torino, Italy
| | - Andrea Fabbri
- Department of Emergency Medicine, Pierantoni Morgagni Hospital, Forlì
| | - Stefano Grifoni
- Department of Emergency Medicine, Careggi University Hospital, Firenze
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Reagle Z, Tringali S, Gill N, Peterson MW. Diagnostic yield and renal complications after computed tomography pulmonary angiograms performed in a community-based academic hospital. J Community Hosp Intern Med Perspect 2012; 2:17722. [PMID: 23882362 PMCID: PMC3714054 DOI: 10.3402/jchimp.v2i2.17722] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2012] [Revised: 04/24/2012] [Accepted: 05/02/2012] [Indexed: 11/26/2022] Open
Abstract
Background Venous thromboembolism and pulmonary embolism (VTE/PE) remain a diagnostic challenge. The computed tomography pulmonary angiogram (CTPA) has emerged as a popular diagnostic test for PE. However, there is limited data on diagnostic yield and complications in actual clinical settings. Our goal was to determine the diagnostic yield for PE and rate of renal complications following CTPA in a large community hospital setting. Methods A retrospective chart review of 1,514 patients who underwent CTPA in the emergency department or during the initial 24 hours of admission to a community-based academic hospital. Results Of 1,514 CTPAs, 125 were positive for VTE/PE yielding a positive diagnosis in 8.2%. Dyspnea was the most common symptom in patients and a normal physical exam was the most common finding. Among the 925 patients with adequate data to calculate the rate of contrast-induced nephropathy (CIN), 25.8% had an increase of at least 25% in serum creatinine following the CTPA. Pre-existing diabetes and age were the most important predictors of CIN. Conclusions CTPA has a low diagnostic yield for PE in a community setting, and in some patient populations, the rate of contrast-induced nephropathy may be higher than previously reported in the literature. Due to the retrospective nature of this study we were limited in using pre-test scoring systems and in measuring the impact of alternative CT diagnoses on patient management.
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