Rationale and Objectives
Present methods for measuring adherence to national imaging quality measures often require a resource-intensive chart review. Computerized decision support systems may allow for automated capture of these data. We sought to determine the feasibility of measuring adherence to a national quality measure (NQM) regarding computed tomography pulmonary angiograms (CTPAs) for pulmonary embolism using measure-targeted clinical decision support and whether the associated increased burden of data captured required by this system would affect the use and yield of CTs.
Materials and Methods
This institutional review board–approved prospective cohort study enrolled patients from September 1, 2009, through November 30, 2011, in the emergency department (ED) of a 776-bed quaternary-care adults-only academic medical center. Our intervention consisted of an NQM-targeted clinical decision support tool for CTPAs, which required mandatory input of the Wells criteria and serum D-dimer level. The primary outcome was the documented adherence to the quality measure prior and subsequent to the intervention, and the secondary outcomes were the use and yield of CTPAs.
Results
A total of 1209 patients with suspected PE (2.0% of 58,795 ED visits) were imaged by CTPA during the 12-month control period, and 1212 patients were imaged in the 12 months after the quarter during which the intervention was implemented (2.0% of 59,478 ED visits, P = .84). Documented baseline adherence to the NQM was 56.9% based on a structured review of the provider notes. After implementation, documented adherence increased to 75.6% ( P < .01). CTPA yield remained unchanged and was 10.4% during the control period and 10.1% after the intervention ( P = .88).
Conclusions
Implementation of a clinical decision support tool significantly improved documented adherence to an NQM, enabling automated measurement of provider adherence to evidence without the need for resource-intensive chart review. It did not adversely affect the use or yield of CTPAs.
Present health care reform initiatives focus on increasing value, improving quality, and reducing waste, often through the use of publicly reported national quality measures (NQMs) . Much of this activity has been directed toward the use of high-cost imaging such as computed tomography (CT), the use of which has increased significantly over the past two decades . Although CT is useful because of its diagnostic speed and accuracy , it has come under scrutiny because of its potential for inappropriate use, especially in the emergency department (ED) , and its potential risks of radiation exposure and contrast-induced nephropathy .
One area of intense focus is the ED use of CT for patients with suspected pulmonary embolism (PE). Although validated, evidence-based decision tools designed to help clinicians to identify patients who need imaging have been available for more than 12 years and are now endorsed by multiple specialty societies , inappropriate use continues, and educational interventions have not been shown to improve appropriateness . An evidence-based NQM was recently endorsed by the National Quality Forum but, in a recent study, one-third of the CT pulmonary angiograms (CTPAs) performed in ED patients with suspected PE did not adhere to it . Another recent study demonstrated that pretest probabilities are rarely documented by emergency physicians before obtaining CTPAs . Additionally, a number of public comments regarding the NQM cited concerns regarding the level of intensive manual chart review that would be necessary to gather the granular data required to determine whether CTPAs were adherent to evidence .
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Materials and methods
Study Design and Setting
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Study Participants
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Intervention
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Sample Size
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Data Collection
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Statistical Analyses
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Results
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Table 1
Comparison of Control and Intervention Patient Cohorts
Control Period Intervention Period_P_ Value Age, y (SD) 56.0 (16.9) 55.1 (17.0) .81 Male 36.7% 38.4% .70 Use of CTPA, % of all ED visits 2.1% 2.0% .84 NQM adherence 56.9% 75.6%0.008 CTPA yield 10.4% 10.1% .88
CTPA, computed tomography pulmonary angiography; ED, emergency department; NQM, national quality measure; SD, standard deviation.
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Discussion
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