RESPECT-ED: Rates of pulmonary Emboli (PE) and Sub-segmental PE with modern Computed Tomographic pulmonary angiograms in Emergency Departments: A multi-center observational study finds significant yield variation, uncorrelated with use or small PE rates

David Mountain, Gerben Keijzers, Kevin Chu, Anthony Joseph, Catherine Read, Gabriel Blecher, Jeremy Furyk, Chrianna Bharat, Karthik Velusamy, Andrew Munro, Kylie Baker, Frances Kinnear, Ahses Mukherjee, Gina Watkins, Paul Buntine, Georgia Livesay, Daniel Fatovich

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Abstract

Introduction: Overuse of CT Pulmonary Angiograms (CTPA) for diagnosing pulmonary embolism (PE), particularly in Emergency Departments (ED), is considered problematic. Marked variations in positive CTPA rates are reported, with American 4-10% yields driving most concerns. Higher resolution CTPA may increase sub-segmental PE (SSPE) diagnoses, which may be up to 40% false positive. Excessive use and false positives could increase harm vs. benefit. These issues have not been systematically examined outside America. Aims: To describe current yield variation and CTPA utilisation in Australasian ED, exploring potential factors correlated with variation. Methods: A retrospective multi-centre review of consecutive ED-ordered CTPA using standard radiology reports. ED CTPA report data were inputted onto preformatted data-sheets. The primary outcome was site level yield, analysed both intra-site and against a nominated 15.3% yield. Factors potentially associated with yield were assessed for correlation. Results: Fourteen radiology departments (15 ED) provided 7077 CTPA data (94% ≥64-slice CT); PE were reported in 1028 (yield 14.6% (95%CI 13.8-15.4%; range 9.3-25.3%; site variation p <0.0001) with four sites significantly below and one above the 15.3% target. Admissions, CTPA usage, PE diagnosis rates and size of PE were uncorrelated with yield. Large PE (≥lobar) were 55% (CI: 52.1-58.2%) and SSPE 8.8% (CI: 7.1-10.5%) of positive scans. CTPA usage (0.2-1.5% adult attendances) was correlated (p<0.006) with PE diagnosis but not SSPE: large PE proportions. Discussion/ Conclusions: We found significant intra-site CTPA yield variation within Australasia. Yield was not clearly correlated with CTPA usage or increased small PE rates. Both SSPE and large PE rates were similar to higher yield historical cohorts. CTPA use was considerably below USA 2.5-3% rates. Higher CTPA utilisation was positively correlated with PE diagnoses, but without evidence of increased proportions of small PE. This suggests that increased diagnoses seem to be of clinically relevant sized PE.

Original languageEnglish
Article numbere0166483
JournalPLoS One
Volume11
Issue number12
DOIs
Publication statusPublished - 1 Dec 2016
Externally publishedYes

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embolism
observational studies
Embolism
Observational Studies
Hospital Emergency Service
Angiography
lungs
Lung
Radiology
radiology

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Mountain, David ; Keijzers, Gerben ; Chu, Kevin ; Joseph, Anthony ; Read, Catherine ; Blecher, Gabriel ; Furyk, Jeremy ; Bharat, Chrianna ; Velusamy, Karthik ; Munro, Andrew ; Baker, Kylie ; Kinnear, Frances ; Mukherjee, Ahses ; Watkins, Gina ; Buntine, Paul ; Livesay, Georgia ; Fatovich, Daniel. / RESPECT-ED : Rates of pulmonary Emboli (PE) and Sub-segmental PE with modern Computed Tomographic pulmonary angiograms in Emergency Departments: A multi-center observational study finds significant yield variation, uncorrelated with use or small PE rates. In: PLoS One. 2016 ; Vol. 11, No. 12.
@article{5d95041d010145b0882875d053f17fd5,
title = "RESPECT-ED: Rates of pulmonary Emboli (PE) and Sub-segmental PE with modern Computed Tomographic pulmonary angiograms in Emergency Departments: A multi-center observational study finds significant yield variation, uncorrelated with use or small PE rates",
abstract = "Introduction: Overuse of CT Pulmonary Angiograms (CTPA) for diagnosing pulmonary embolism (PE), particularly in Emergency Departments (ED), is considered problematic. Marked variations in positive CTPA rates are reported, with American 4-10{\%} yields driving most concerns. Higher resolution CTPA may increase sub-segmental PE (SSPE) diagnoses, which may be up to 40{\%} false positive. Excessive use and false positives could increase harm vs. benefit. These issues have not been systematically examined outside America. Aims: To describe current yield variation and CTPA utilisation in Australasian ED, exploring potential factors correlated with variation. Methods: A retrospective multi-centre review of consecutive ED-ordered CTPA using standard radiology reports. ED CTPA report data were inputted onto preformatted data-sheets. The primary outcome was site level yield, analysed both intra-site and against a nominated 15.3{\%} yield. Factors potentially associated with yield were assessed for correlation. Results: Fourteen radiology departments (15 ED) provided 7077 CTPA data (94{\%} ≥64-slice CT); PE were reported in 1028 (yield 14.6{\%} (95{\%}CI 13.8-15.4{\%}; range 9.3-25.3{\%}; site variation p <0.0001) with four sites significantly below and one above the 15.3{\%} target. Admissions, CTPA usage, PE diagnosis rates and size of PE were uncorrelated with yield. Large PE (≥lobar) were 55{\%} (CI: 52.1-58.2{\%}) and SSPE 8.8{\%} (CI: 7.1-10.5{\%}) of positive scans. CTPA usage (0.2-1.5{\%} adult attendances) was correlated (p<0.006) with PE diagnosis but not SSPE: large PE proportions. Discussion/ Conclusions: We found significant intra-site CTPA yield variation within Australasia. Yield was not clearly correlated with CTPA usage or increased small PE rates. Both SSPE and large PE rates were similar to higher yield historical cohorts. CTPA use was considerably below USA 2.5-3{\%} rates. Higher CTPA utilisation was positively correlated with PE diagnoses, but without evidence of increased proportions of small PE. This suggests that increased diagnoses seem to be of clinically relevant sized PE.",
author = "David Mountain and Gerben Keijzers and Kevin Chu and Anthony Joseph and Catherine Read and Gabriel Blecher and Jeremy Furyk and Chrianna Bharat and Karthik Velusamy and Andrew Munro and Kylie Baker and Frances Kinnear and Ahses Mukherjee and Gina Watkins and Paul Buntine and Georgia Livesay and Daniel Fatovich",
year = "2016",
month = "12",
day = "1",
doi = "10.1371/journal.pone.0166483",
language = "English",
volume = "11",
journal = "PLoS One",
issn = "1932-6203",
publisher = "Public Library of Science",
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}

Mountain, D, Keijzers, G, Chu, K, Joseph, A, Read, C, Blecher, G, Furyk, J, Bharat, C, Velusamy, K, Munro, A, Baker, K, Kinnear, F, Mukherjee, A, Watkins, G, Buntine, P, Livesay, G & Fatovich, D 2016, 'RESPECT-ED: Rates of pulmonary Emboli (PE) and Sub-segmental PE with modern Computed Tomographic pulmonary angiograms in Emergency Departments: A multi-center observational study finds significant yield variation, uncorrelated with use or small PE rates' PLoS One, vol. 11, no. 12, e0166483. https://doi.org/10.1371/journal.pone.0166483

RESPECT-ED : Rates of pulmonary Emboli (PE) and Sub-segmental PE with modern Computed Tomographic pulmonary angiograms in Emergency Departments: A multi-center observational study finds significant yield variation, uncorrelated with use or small PE rates. / Mountain, David; Keijzers, Gerben; Chu, Kevin; Joseph, Anthony; Read, Catherine; Blecher, Gabriel; Furyk, Jeremy; Bharat, Chrianna; Velusamy, Karthik; Munro, Andrew; Baker, Kylie; Kinnear, Frances; Mukherjee, Ahses; Watkins, Gina; Buntine, Paul; Livesay, Georgia; Fatovich, Daniel.

In: PLoS One, Vol. 11, No. 12, e0166483, 01.12.2016.

Research output: Contribution to journalArticleResearchpeer-review

TY - JOUR

T1 - RESPECT-ED

T2 - Rates of pulmonary Emboli (PE) and Sub-segmental PE with modern Computed Tomographic pulmonary angiograms in Emergency Departments: A multi-center observational study finds significant yield variation, uncorrelated with use or small PE rates

AU - Mountain, David

AU - Keijzers, Gerben

AU - Chu, Kevin

AU - Joseph, Anthony

AU - Read, Catherine

AU - Blecher, Gabriel

AU - Furyk, Jeremy

AU - Bharat, Chrianna

AU - Velusamy, Karthik

AU - Munro, Andrew

AU - Baker, Kylie

AU - Kinnear, Frances

AU - Mukherjee, Ahses

AU - Watkins, Gina

AU - Buntine, Paul

AU - Livesay, Georgia

AU - Fatovich, Daniel

PY - 2016/12/1

Y1 - 2016/12/1

N2 - Introduction: Overuse of CT Pulmonary Angiograms (CTPA) for diagnosing pulmonary embolism (PE), particularly in Emergency Departments (ED), is considered problematic. Marked variations in positive CTPA rates are reported, with American 4-10% yields driving most concerns. Higher resolution CTPA may increase sub-segmental PE (SSPE) diagnoses, which may be up to 40% false positive. Excessive use and false positives could increase harm vs. benefit. These issues have not been systematically examined outside America. Aims: To describe current yield variation and CTPA utilisation in Australasian ED, exploring potential factors correlated with variation. Methods: A retrospective multi-centre review of consecutive ED-ordered CTPA using standard radiology reports. ED CTPA report data were inputted onto preformatted data-sheets. The primary outcome was site level yield, analysed both intra-site and against a nominated 15.3% yield. Factors potentially associated with yield were assessed for correlation. Results: Fourteen radiology departments (15 ED) provided 7077 CTPA data (94% ≥64-slice CT); PE were reported in 1028 (yield 14.6% (95%CI 13.8-15.4%; range 9.3-25.3%; site variation p <0.0001) with four sites significantly below and one above the 15.3% target. Admissions, CTPA usage, PE diagnosis rates and size of PE were uncorrelated with yield. Large PE (≥lobar) were 55% (CI: 52.1-58.2%) and SSPE 8.8% (CI: 7.1-10.5%) of positive scans. CTPA usage (0.2-1.5% adult attendances) was correlated (p<0.006) with PE diagnosis but not SSPE: large PE proportions. Discussion/ Conclusions: We found significant intra-site CTPA yield variation within Australasia. Yield was not clearly correlated with CTPA usage or increased small PE rates. Both SSPE and large PE rates were similar to higher yield historical cohorts. CTPA use was considerably below USA 2.5-3% rates. Higher CTPA utilisation was positively correlated with PE diagnoses, but without evidence of increased proportions of small PE. This suggests that increased diagnoses seem to be of clinically relevant sized PE.

AB - Introduction: Overuse of CT Pulmonary Angiograms (CTPA) for diagnosing pulmonary embolism (PE), particularly in Emergency Departments (ED), is considered problematic. Marked variations in positive CTPA rates are reported, with American 4-10% yields driving most concerns. Higher resolution CTPA may increase sub-segmental PE (SSPE) diagnoses, which may be up to 40% false positive. Excessive use and false positives could increase harm vs. benefit. These issues have not been systematically examined outside America. Aims: To describe current yield variation and CTPA utilisation in Australasian ED, exploring potential factors correlated with variation. Methods: A retrospective multi-centre review of consecutive ED-ordered CTPA using standard radiology reports. ED CTPA report data were inputted onto preformatted data-sheets. The primary outcome was site level yield, analysed both intra-site and against a nominated 15.3% yield. Factors potentially associated with yield were assessed for correlation. Results: Fourteen radiology departments (15 ED) provided 7077 CTPA data (94% ≥64-slice CT); PE were reported in 1028 (yield 14.6% (95%CI 13.8-15.4%; range 9.3-25.3%; site variation p <0.0001) with four sites significantly below and one above the 15.3% target. Admissions, CTPA usage, PE diagnosis rates and size of PE were uncorrelated with yield. Large PE (≥lobar) were 55% (CI: 52.1-58.2%) and SSPE 8.8% (CI: 7.1-10.5%) of positive scans. CTPA usage (0.2-1.5% adult attendances) was correlated (p<0.006) with PE diagnosis but not SSPE: large PE proportions. Discussion/ Conclusions: We found significant intra-site CTPA yield variation within Australasia. Yield was not clearly correlated with CTPA usage or increased small PE rates. Both SSPE and large PE rates were similar to higher yield historical cohorts. CTPA use was considerably below USA 2.5-3% rates. Higher CTPA utilisation was positively correlated with PE diagnoses, but without evidence of increased proportions of small PE. This suggests that increased diagnoses seem to be of clinically relevant sized PE.

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