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
Facilitators and Barriers
There are significant limitations with respect to the analysis of the factors that favor or impede the implementation of the interventions appraised in this review. However, 2 studies that did not meet the inclusion criteria appraised physicians’ perceptions and attitudes toward prescribing imaging tests in the diagnostic workup of PE.31,32 One is Swiss31 and the other is Canadian.32 Both were conducted in the ED of academic hospitals. Rohacek et al.31 observed that defensive behaviors, such as “fear of missing PE,” were frequent and associated with a lower probability of a positive CTPA (OR = 0.36; 95% CI, 0.14-0.92). Ahn et al.32 concluded that, although ED physicians who participated in their survey possessed limited knowledge of radiation doses of CTPA and V/Q scans, they opted for V/Q scans that emit lower radiation doses in younger patients, especially females, which may reflect efforts done in the study setting to reduce patients’ radiation exposure.
There is not enough data to conclude on safety and the impact on healthcare costs.
Implications for Future Research
Future controlled studies of high methodological quality would help to better understand the effects associated with the implementation of the interventions aimed at reducing the inappropriate use of imaging in the diagnostic workup of PE. Efficacy results show that the success of the implementation of the various types of interventions is variable. This variation may be at least partly attributable to contextual factors, such as the external environment, the organizational leadership and culture, or the microsystem, such as differences in care patterns.33-35 The impact of context factors on the effectiveness of the interventions should be assessed further with appropriate tools.33,34,36
CONCLUSION
The joint use of CDS and PFRs appears more effective than the other types of intervention in reducing the inappropriate use of CTPA. However, an approach combining these with well-designed educational interventions as well as policies may be even more effective.
Future studies of high methodological quality would strengthen the evidence concerning the relative efficacy and safety of the interventions appraised, especially when various types are combined. Future research should also aim at bringing answers to the knowledge gaps related to the factors of success and barriers associated with the implementation of the interventions.
Disclosure
The authors report no conflict of interest.
