Rationale and Objectives
We sought to evaluate the effectiveness of e-mail communication to reduce the utilization of computed tomography for pulmonary thromboembolism (PE) in young patients (aged 40 and under) in our institution.
Materials and Methods
An e-mail was sent to all of our institution’s emergency department (ED) physicians in response to a series of negative PE studies in young females. The periods 90 days before and 90 days after were evaluated to assess the total number of PE studies performed in patients aged 40 and younger, the rate of positivity, and the utilization of D-dimer and ventilation/perfusion scans during each period.
Results
Over the 180-day period, a total of 65 PE studies were ordered in patients aged 40 and younger in the ED. Studies were positive for PE in 1 of 33 (3%) before the e-mail and 4 of 32 (12.5%) after ( P = .343). There was no difference in the number of D-dimer studies ordered during each period for patients studied with computed tomography. Ventilation/perfusion scanning was not performed on any ED patients younger than 40 during the 180-day period.
Conclusions
One-time e-mail communication was not effective in changing ED ordering habits of PE studies. Scant information exists in regard to effective clinician-to-clinician communication. Further evaluation for successful mechanisms to promote health practice reform and quality improvement is necessary.
With an estimated annual incidence rate of 0.1% ( ), approximately 300,000 people in the United States are expected to be diagnosed with pulmonary embolism (PE) each year. If PE is recognized and treated, mortality is relatively low; however, a multicenter trial found all-cause mortality for patients with PE to be 17% at 3 months ( ). Thus, PE accounts for roughly 50,000 deaths in the United States per year.
Computed tomographic (CT) pulmonary angiography (CTPA) has become the diagnostic test of choice for PE owing to its high negative predictive value ( ). This success is a double-edge sword—as techniques improve and availability increases, ordering patterns have shifted to a greater reliance on CTPA even in those patients with a low pretest probability. In the Prospective Investigation of Pulmonary Embolism Diagnosis (PIOPED I) study, the positive rate of patients who underwent evaluation for pulmonary embolus was 33% ( ). The positive rate for patients undergoing CTPA appears to be decreasing and in one institution dropped from 27% to 16% over a 5-year period ( ). In the emergency department (ED), positivity rates may be even lower, with one study showing a CTPA positivity rate of 13.7% even after excluding low-risk subjects ( ). Positive rates range from 8% to 14% in our institution depending on the ordering service and remain between 10% and 12% for the ED (unpublished data from periodic quality assurance review).
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Materials And Methods
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“The number of PE studies from the ED has been trending upwards, in some cases five in one night. It may well be that all are justifiable and indicated, but I fear that it may become the de facto chest radiograph. The doses of a CT PE study confer between a 5–15% increase in the risk of development of breast cancer in women under the age of 35. In young women with a negative chest radiograph, I would ask that ordering a V/Q scan be considered.”
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Statistical Analysis
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Results
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Table 1
Comparison of Pre−E-mail and Post−E-mail Correspondence for CT Positivity, D-dimer Ordering, and V̇/Q̇ Scans Performed
Pre−E-mail ( n = 33) Post−E-mail ( n = 32)P -value CT positivity 1/33 (3.03%) 4/32 (12.5%) .34 D-dimer ordered 13/33 (39.4%) 15/32 (46.9%) .98 D-dimer Positive 9/13 (69.2%) 11/13 (84.6%) .74 V̇/Q̇ scan performed 0/33 0/32 1.00
Values are given as frequency (%). All P values are derived from the χ 2 /Fisher’s test.
\* P < .05.
Table 2
Common Indications and Predisposing Conditions for PE Studies
Condition Pre−E-mail Post−E-mail Chest pain 19 20 Shortness of breath 21 17 Tachycardia 6 1 Postpartum 2 7 Malignancy 4 1 Prior PE, DVT, or DVT symptoms 9 4
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Discussion
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Conclusion
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