From the, Department of Emergency Medicine, University of Massachusetts Medical School-Baystate, Springfield, MA.
the, Institute for Healthcare Delivery and Population Science, University of Massachusetts Medical School-Baystate, Springfield, MA.
Acad Emerg Med. 2020 Jun;27(6):447-456. doi: 10.1111/acem.13908. Epub 2020 Mar 27.
Providers often pursue imaging in patients at low risk of pulmonary embolism (PE), resulting in imaging yields <10% and false-positive imaging rates of 10% to 25%. Attempts to curb overtesting have had only modest success and no interventions have used implementation science frameworks. The objective of this study was to identify barriers and facilitators to the adoption of evidence-based diagnostic testing for PE.
We conducted semistructured interviews with a purposeful sample of providers. An interview guide was developed using the implementation science frameworks, consolidated framework for implementation research, and theoretical domains framework. Interviews were recorded, transcribed, and analyzed in an iterative process. Emergent themes were identified, discussed, and organized.
We interviewed 23 providers from four hospital systems, and participants were diverse with regard to years in practice and practice setting. Barriers were predominately at the provider level and included lack of knowledge of the tools, particularly misunderstanding of the validated scoring systems in Wells, as well as risk avoidance and need for certainty. Barriers to prior implementation strategies included the perception of a clinical decision support (CDS) tool for PE as adding steps with little value; most participants reported that they overrode CDS interventions because they had already made the decision. All providers identified institution-level strategies as facilitators to use, including endorsed guidelines, audit feedback with peer comparison about imaging yield, and peer pressure.
This exploration of the use of risk stratification tools in the evaluation of PE found that barriers to use primarily exist at the provider level, whereas facilitators to the use of these tools are largely perceived at the level of the institution. Future efforts to promote the evidence-based diagnosis of PE should be informed by these determinants.
医生常对低风险肺栓塞（PE）患者进行影像学检查，导致影像学检出率<10%，假阳性率为 10%~25%。尽管已经尝试采取措施来减少过度检测，但收效甚微，且没有任何干预措施使用实施科学框架。本研究旨在确定采用基于证据的 PE 诊断检测方法的障碍和促进因素。
我们采用实施科学框架、综合实施研究框架和理论领域框架，对有代表性的医务人员进行半结构式访谈。访谈前制定访谈指南，采用迭代法对访谈进行记录、转录和分析。确定、讨论和组织出现的主题。
我们对来自四个医院系统的 23 名医务人员进行了访谈，参与者在实践年限和实践环境方面存在差异。障碍主要出现在提供者层面，包括对工具缺乏了解，特别是对 Wells 验证评分系统的误解，以及风险规避和对确定性的需求。先前实施策略的障碍包括将 PE 的临床决策支持（CDS）工具视为增加价值不大的步骤；大多数参与者报告说，他们会忽略 CDS 干预，因为他们已经做出了决定。所有提供者都认为机构层面的策略是使用的促进因素，包括认可的指南、带有同行比较的影像学产出审计反馈，以及同行压力。
本研究对 PE 评估中风险分层工具的使用进行了探索，发现使用障碍主要存在于提供者层面，而这些工具的使用促进因素主要存在于机构层面。未来促进基于证据的 PE 诊断的努力应考虑这些决定因素。
