Multiple decision rules have been developed to improve the use of computed tomographic pulmonary angiography in patients with suspected pulmonary embolism in the emergency department. And clinical trials have shown that all of these decision rules decrease how frequently clinicians use this type of imaging. The study described in this article used real-world data from 26 emergency departments in 6 European countries to address the same issue and found something different.
Abstract
Background:
Recently, validated clinical decision rules have been developed that avoid unnecessary use of computed tomographic pulmonary angiography (CTPA) in patients with suspected pulmonary embolism (PE) in the emergency department (ED).
Objective:
To measure any resulting change in CTPA use for suspected PE.
Design:
Retrospective analysis.
Setting:
26 European EDs in 6 countries.
Patients:
Patients with CTPA performed for suspected PE in the ED during the first 7 days of each odd month between January 2015 and December 2019.
Measurements:
The primary end points were the CTPAs done for suspected PE in the ED and the number of PEs diagnosed in the ED each year adjusted to an annual census of 100 000 ED visits. Temporal trends were estimated using generalized linear mixed regression models.
Results:
8970 CTPAs were included (median age, 63 years; 56% female). Statistically significant temporal trends for more frequent use of CTPA (836 per 100 000 ED visits in 2015 vs. 1112 in 2019; P < 0.001), more diagnosed PEs (138 per 100 000 in 2015 vs. 164 in 2019; P = 0.028), a higher proportion of low-risk PEs (annual percent change [APC], 13.8% [95% CI, 2.6% to 30.1%]) with more ambulatory management (APC, 19.3% [CI, 4.1% to 45.1%]), and a lower proportion of intensive care unit admissions (APC, −8.9% [CI, −17.1% to −0.3%]) were observed.
Limitation:
Data were limited to 7 days every 2 months.
Conclusion:
Despite the recent validation of clinical decision rules to limit the use of CTPA, an increase in the CTPA rate along with more diagnosed PEs and especially low-risk PEs were instead observed.
Primary Funding Source:
None specific for this study.
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Author, Article, and Disclosure Information
Melanie Roussel,
Sorbonne Université, UMR Inserm 1166, IHU ICAN, Paris; Emergency Department, Hôpital Pitié-Salpêtrière, Assistance Publique–Hôpitaux de Paris, Paris, France (M.R., Y.F.)
Emergency Department, Royal London Hospital, London, United Kingdom (B.B.)
Emergency Department, Rouen University Hospital, Rouen, France (M.T.)
Emergency Department, Hôpital Bichat, Assistance Publique–Hôpitaux de Paris, Paris, France (C. Choquet)
Department of Emergency Medicine, University Hospital of Angers, Angers; and UNIV Angers, UMR MitoVasc CNRS 6215 INSERM 1083, Angers, France (D.D.)
Emergency Department, Hôpital Européen Georges-Pompidou, Assistance Publique–Hôpitaux de Paris, Université Paris Cite, Paris; and Toxicology and Chemical Risks Department, French Armed Forces Biomedical Institute, Brétigny-sur-Orge, France (F.F.)
Emergency Department, Hôpital Pitié-Salpêtrière, Assistance Publique–Hôpitaux de Paris, Paris, France (A. Marouk)
Emergency Department, Hôpital Avicenne, Assistance Publique–Hôpitaux de Paris, Bobigny, France (J. Golicki)
Emergency Department, Hôpital Saint-Joseph, Paris, France (C.G.)
Emergency Department, CHU Caen Côte de Nacre, Normandie Université UNICAEN, INSERM PhIND Institut Blood and Brain, Caen, France (R.M.)
Department of Emergency Medicine, Amiens-Picardy University Hospital, Amiens, France (E.A.)
Emergency Department, Hôpital Tenon, Assistance Publique–Hôpitaux de Paris, Paris, France (R.B.)
Emergency Department, CHU Nantes, Nantes, France (E.M.)
Emergency Department, Lausanne University Hospital Emergency Care Service, Lausanne, Switzerland (O.H.)
Emergency Department, Hôpital Saint-Antoine, Assistance Publique–Hôpitaux de Paris, Paris, France (C. Czopik)
Emergency Department, Hôpital Lariboisière, Assistance Publique–Hôpitaux de Paris, Paris, France (X.E.)
Emergency Department, Hospices Civils de Lyon, Lyon, France (A.B., M.D.)
Emergency Department, Hôpital Saint-Louis, Assistance Publique–Hôpitaux de Paris, Paris, France (O.P.)
Emergency Department, University Hospital of Nancy, Nancy, France (T.C.)
Emergency Department, Cliniques Universitaires Saint-Luc, Brussels, Belgium (A.P.)
Emergency Department, ASST Papa Giovanni XXIII, Bergamo, Italy (A. Marra)
Tours University, Emergency Medicine Department, Tours University Hospital, Tours, France (S.L.)
Emergency Department, Hôpital Ambroise Paré, Assistance Publique–Hôpitaux de Paris, Boulogne; and Université Versailles–Saint Quentin en Yvelines, Boulogne, France (P.-G.R.)
Department of Emergency Medicine, Medical University Vienna, Vienna General Hospital, Vienna, Austria (W.B.)
Emergency Department, University Hospital of Poitiers, Poitiers, France (J. Guenezen)
Emergency Department, Hôpital Louis-Mourier, Assistance Publique–Hôpitaux de Paris, Colombes; and Reference Center for Bradykinin Angiodema (CReAk), Université Paris Cite, Colombes, France (N.J.)
Sorbonne Université, UMR Inserm 1166, IHU ICAN, Paris; and Sorbonne Université, CNRS, INSERM, Laboratoire d’Imagerie Biomédicale LIB, Paris, France (O.L.)
Department of Clinical Pharmacology and Clinical Research Platform Paris-East (URCEST-CRC-CRB), Hôpital Saint-Antoine, Assistance Publique–Hôpitaux de Paris, Paris, France (M.C., A.A.).
Acknowledgment: The authors would like to thank Tabassome Simon, MD, PhD (Sorbonne Université and Assistance Publique–Hôpitaux de Paris [APHP], Clinical Research Platform Paris-East); Vanessa Lemaitre, MSc (FHU IMPEC); Sara Salhi, MSc (Clinical Research Platform Paris-East, APHP); and Sophie Courtial-Destembert (Délégation de la Recherche Clinique et de l’Innovation of APHP) for their valuable help and support.
Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M22-3116.
Reproducible Research Statement: Study protocol and Statistical code: Available upon request. Data set: Available upon request and agreement of all participating centers.
Corresponding Author: Yonathan Freund, MD, PhD, Service d’Accueil des Urgences, 83 Boulevard de l’Hôpital, 75013 Paris, France; e-mail, yonathan.
Author Contributions: Conception and design: B. Bloom, Y. Freund, M. Roussel.
Analysis and interpretation of the data: B. Bloom, Y. Freund, O. Lucidarme, M. Roussel, A. Aparicio-Monforte, M. Cachanado.
Drafting of the article: B. Bloom, M. Cachanado, Y. Freund, M. Roussel.
Critical revision of the article for important intellectual content: A. Aparicio-Monforte, E. Arnaud, W. Behringer, A. Benhamed, B. Bloom, R. Bompard, M. Cachanado, C. Choquet, T. Chouihed, C. Czopik, D. Douillet, M. Douplat, X. Eyer, F. Fémy, Y. Freund, C. Gerlier, J. Gorlicki, J. Guenezan, O. Hugli, N. Javaud, S. Laribi, O. Lucidarme, R. Macrez, A. Marouk, A. Marra, E. Montassier, A. Penaloza, O. Peyrony, P.-G. Reuter, M. Roussel, M. Taalba.
Final approval of the article: A. Aparicio-Monforte, E. Arnaud, W. Behringer, A. Benhamed, B. Bloom, R. Bompard, M. Cachanado, C. Choquet, T. Chouihed, C. Czopik, D. Douillet, M. Douplat, X. Eyer, F. Fémy, Y. Freund, C. Gerlier, J. Gorlicki, J. Guenezan, O. Hugli, N. Javaud, S. Laribi, O. Lucidarme, R. Macrez, A. Marouk, A. Marra, E. Montassier, A. Penaloza, O. Peyrony, P.-G. Reuter, M. Roussel, M. Taalba.
Provision of study materials or patients: E. Arnaud, W. Behringer, A. Benhamed, B. Bloom, R. Bompard, C. Choquet, T. Chouihed, C. Czopik, D. Douillet, M. Douplat, X. Eyer, F. Fémy, Y. Freund, C. Gerlier, J. Gorlicki, J. Guenezan, O. Hugli, N. Javaud, S. Laribi, O. Lucidarme, R. Macrez, A. Marouk, A. Marra, E. Montassier, A. Penaloza, O. Peyrony, P.-G. Reuter, M. Roussel, M. Taalba.
Statistical expertise: A. Aparicio-Monforte, M. Cachanado.
Collection and assembly of data: E. Arnaud, W. Behringer, A. Benhamed, B. Bloom, R. Bompard, C. Choquet, T. Chouihed, C. Czopik, D. Douillet, M. Douplat, X. Eyer, F. Fémy, Y. Freund, C. Gerlier, J. Gorlicki, J. Guenezan, O. Hugli, N. Javaud, S. Laribi, O. Lucidarme, R. Macrez, A. Marouk, A. Marra, E. Montassier, A. Penaloza, O. Peyrony, P.-G. Reuter, M. Roussel, M. Taalba.
This article was published at Annals.org on 23 May 2023.
* For members of the Improving Emergency Care (IMPEC) FHU Collaborator Group, see the Appendix.
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