Interventions to Reduce the Overuse of Imaging for Pulmonary Embolism: A Systematic Review
BACKGROUND: Imaging use in the diagnostic workup of pulmonary embolism (PE) has increased markedly in the last 2 decades. Low PE prevalence and diagnostic yields suggest a significant problem of overuse.
PURPOSE: The purpose of this systematic review is to summarize the evidence associated with the interventions aimed at reducing the overuse of imaging in the diagnostic workup of PE in the emergency department and hospital wards.
DATA SOURCES: PubMed, MEDLINE, Embase, and EBM Reviews from 1998 to March 28, 2017.
STUDY SELECTION: Experimental and observational studies were included. The types of interventions, their efficacy and safety, the impact on healthcare costs, the facilitators, and barriers to their implementation were assessed.
DATA SYNTHESIS: Seventeen studies were included assessing clinical decision support (CDS), educational interventions, performance and feedback reports (PFRs), and institutional policy. CDS impact was most comprehensively documented. It was associated with a reduction in imaging use, ranging from 8.3% to 25.4%, and an increase in diagnostic yield, ranging from 3.4% to 4.4%. The combined implementation of a CDS and PFR resulted in a modest but significant increase in the adherence to guidelines. Few studies appraised the safety of interventions. There was a lack of evidence concerning economic aspects, facilitators, and barriers.
CONCLUSIONS: A combined implementation of an electronic CDS and PFRs is more effective than purely educational or policy interventions, although evidence is limited. Future studies of high-methodological quality would strengthen the evidence concerning their efficacy, safety, facilitators, and barriers.
© 2018 Society of Hospital Medicine
Economic Aspects
Kline et al.13 (2014) found a significant decrease in charges and estimated costs for medical care within 90 days of initial ED presentation in the patients who were investigated with CTPA in the intervention group. The median costs of medical care within 30 days of the initial ED presentation were US $1274 in the control group and US $934 in the intervention group (P = .018).13 The median charges of medical care within 30 days of the initial ED presentation were US $7595 in the control group and US $6281 in the intervention group (P = .004).13
Facilitators and Barriers
Only 1 study appraised the reasons given by emergency physicians for not adhering to CDS recommendations.16 The reason most often given was the time needed to access and use the application, which was perceived as having a negative impact on productivity as well as a preference for intuitive clinical judgment.16 Though not the result of specific evaluation or data collection, some authors commented on the factors that may facilitate or impede the implementation of interventions to diminish the inappropriate use.14,20 Kanaan et al.20 proposed that factors other than the knowledge of current clinical guidelines may explain CTPA use. Booker and Johnson26 suggested that the demand for rapid turnover in the ED may lead to “so-called ‘blanket ordering’, which attempts to reach diagnosis as quickly as possible despite cost and patient safety.” Raja et al.14 (2015) suggested that the unambiguous representation of guidelines based on validated, high-quality evidence in the CDS may have improved physician adoption in their study.
DISCUSSION
Efficacy
Baseline values for the use of imaging and diagnostic yield show important variation, especially when compared with the study performed in Europe.19 In general, only a modest impact is measured with regard to a decrease in the use of imaging, an increase in diagnostic use, and adherence to validated CDRs.
Among the interventions appraised, CDS was evaluated in the largest number of included studies, and its
The impact of CDS on diagnostic yield was mixed because 3 studies observed an increase in diagnostic yield postintervention,16,21,22 and 3 others monitored no significant impact.19,24,28 Adherence to guidelines or a quality measure was assessed in 2 studies, which reported a significant increase in appropriate ordering.17,24 Raja et al.24 (2014) observed an 18.7% increase in appropriate ordering after the implementation of a CDS from 56.9% to 75.6% (P < .01). Geeting et al.17 observed a similar increase, with appropriate ordering increasing from 58% to 76% over the duration of the intervention. However, this increase in appropriate use was not associated with a variation in CTPA use or diagnostic yield, which leads the investigators to posit that the physicians gradually inflated the Wells score they keyed into the CDS despite that no threshold Wells score was required to perform a CTPA.17
Raja et al.14 (2015) demonstrated that the implementation of performance feedback reporting, in addition to a CDS, can significantly increase adherence to CDR for the evaluation of PE in the ED. Additional studies would help to better understand the potential impact of such reports on CTPA use in the diagnostic workup of PE. However, it suggests that a combination of interventions, including the implementation of a CDS, performance feedback reporting, and well-designed and specific educational interventions, may have a more significant impact than any of these types of interventions taken separately.
The impact of the educational interventions appraised in this review on the expected results is mixed, though it is difficult to compare the observed results and draw conclusive remarks, as the characteristics of the interventions and study designs are different from each other.
Safety
There is limited evidence on the safety of appraised interventions. Only 6 studies appraised venous thrombolic events or mortality.13,18,19,23,25,27 However, no adverse events were noted in those studies evaluating possible complications or missed diagnoses. Additional research is needed to confirm the safety of the interventions appraised in this systematic review.
