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Intensive Care Medicine
Published in: Intensive Care Medicine 8/2012

01-08-2012 | Original

Ordering CT pulmonary angiography to exclude pulmonary embolism: defense versus evidence in the emergency room

Authors: Martin Rohacek, Janet Buatsi, Zsolt Szucs-Farkas, Birgit Kleim, Heinz Zimmermann, Aristomenis Exadaktylos, Christoforos Stoupis

Published in: Intensive Care Medicine | Issue 8/2012

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Abstract

Purpose

To identify reasons for ordering computed tomography pulmonary angiography (CTPA), to identify the frequency of reasons for CTPA reflecting defensive behavior and evidence-based behavior, and to identify the impact of defensive medicine and of training about diagnosing pulmonary embolism (PE) on positive results of CTPA.

Methods

Physicians in the emergency department of a tertiary care hospital completed a questionnaire before CTPA after being trained about diagnosing PE and completing questionnaires.

Results

Nine hundred patients received a CTPA during 3 years. For 328 CTPAs performed during the 1-year study period, 140 (43 %) questionnaires were completed. The most frequent reasons for ordering a CTPA were to confirm/rule out PE (93 %), elevated D-dimers (66 %), fear of missing PE (55 %), and Wells/simplified revised Geneva score (53 %). A positive answer for “fear of missing PE” was inversely associated with positive CTPA (OR 0.36, 95 % CI 0.14–0.92, p = 0.033), and “Wells/simplified revised Geneva score” was associated with positive CTPA (OR 3.28, 95 % CI 1.24–8.68, p = 0.017). The proportion of positive CTPA was higher if a questionnaire was completed, compared to the 2-year comparison period (26.4 vs. 14.5 %, OR 2.12, 95 % CI 1.36–3.29, p < 0.001). The proportion of positive CTPA was non-significantly higher during the study period than during the comparison period (19.2 vs. 14.5 %, OR 1.40, 95 % CI 0.98–2.0, p = 0.067).

Conclusion

Reasons for CTPA reflecting defensive behavior—such as “fear of missing PE”—were frequent, and were associated with a decreased odds of positive CTPA. Defensive behavior might be modifiable by training in using guidelines.
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Metadata
Title
Ordering CT pulmonary angiography to exclude pulmonary embolism: defense versus evidence in the emergency room
Authors
Martin Rohacek
Janet Buatsi
Zsolt Szucs-Farkas
Birgit Kleim
Heinz Zimmermann
Aristomenis Exadaktylos
Christoforos Stoupis
Publication date
01-08-2012
Publisher
Springer-Verlag
Published in
Intensive Care Medicine / Issue 8/2012
Print ISSN: 0342-4642
Electronic ISSN: 1432-1238
DOI
https://doi.org/10.1007/s00134-012-2595-z

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