John A. Burns School of Medicine, University of Hawaii, Honolulu, HI, USA.
Hawaii Permanente Medical Group, Emergency Medicine, Honolulu, HI, USA.
Perm J. 2022 Apr 5;26(1):58-63. doi: 10.7812/TPP/21.019.
Computed tomography pulmonary angiography (CTPA) is an imaging study for which there is substantial evidence for its overuse in the evaluation of acute pulmonary embolism (PE). Prior literature has reported low positive PE rates, but the variability in positive rates among the ordering physicians has not been as well studied. The purpose of this study was to evaluate variation in ordering and positive rates among physicians in an emergency department (ED) within an integrated health care system.This study was based in a single ED that is part of a geographically isolated integrated health care system. We reviewed the patient records for all patients who underwent a CTPA for the evaluation for acute PE in the ED between January 1, 2018, and December 31, 2019. For each CTPA examination, we recorded the ordering ED physician, serum d-dimer value (mcg/mL), if any, and the results of the CTPA.Review of CTPAs over the 2-year period revealed 1380 CTPAs ordered by 23 ED physicians with a range of 25-141 studies per physician (mean of 60 + 31 CTPAs). The overall positive rate for PE was 6.9%. Individual ED physician positivity rates showed wide variability ranging from 0% to 18.4% (mean positive rate 7.6 + 4.4%). The results of this study confirm the need for greater adherence to existing guidelines using clinical decision rules and d-dimer testing when appropriate among all ED physicians but especially those who order a greater number of studies and have low rates for positive PE.
计算机断层肺动脉造影（CTPA）是一种影像学检查，已有大量证据表明其在急性肺栓塞（PE）的评估中被过度使用。先前的文献报告了较低的阳性 PE 率，但在开单医生中阳性率的变异性尚未得到很好的研究。本研究的目的是评估在一个综合医疗保健系统内的急诊科（ED）中，医生在开单和阳性率方面的差异。
本研究基于一个 ED，该 ED 是一个地理位置孤立的综合医疗保健系统的一部分。我们回顾了 2018 年 1 月 1 日至 2019 年 12 月 31 日期间在 ED 因急性 PE 接受 CTPA 检查的所有患者的病历。对于每一次 CTPA 检查，我们记录了开单的 ED 医生、血清 D-二聚体值（mcg/mL）（如有）和 CTPA 的结果。
在 2 年的时间里，对 CTPA 的回顾显示，有 23 名 ED 医生共开了 1380 次 CTPA 检查，每位医生的检查范围为 25-141 次（平均 60+31 次）。PE 的总体阳性率为 6.9%。个体 ED 医生的阳性率差异很大，从 0%到 18.4%不等（平均阳性率为 7.6+4.4%）。这项研究的结果证实，所有 ED 医生，特别是那些开单量较大且 PE 阳性率较低的医生，需要更加遵守现有的指南，使用临床决策规则和适当的 D-二聚体检测。
