J Am Coll Radiol. 2023 May 27:S1546-1440(23)00390-3. doi: 10.1016/j.jacr.2023.02.033. Online ahead of print.
ABSTRACT
OBJECTIVE: To evaluate the efficacy of a multi-modal intervention in reducing CT pulmonary angiography (CTPA) overutilization in the evaluation of suspected pulmonary embolism (PE) in the emergency department (ED).
METHODS: Previous mixed methods analysis of barriers to guideline-concordant CTPA ordering results was used to develop a provider focused behavioral intervention consisting of a clinical decision support tool and an audit and feedback system at a multi-site, tertiary academic network. The primary outcome (guideline concordance), and secondary outcomes (yield, and CTPA and D-dimer order rates), were compared using a pre-intervention/post intervention design. ED encounters for adult patients from 7/5/2017 to 1/3/2019 were included. Fisher’s exact tests and statistical process control (SPC) charts were used to compare the pre-/post-intervention groups for each outcome.
RESULTS: Of the 201,912 ED patient visits evaluated, 3,587 included CTPA. Guideline concordance increased significantly after the intervention, from 66.9% to 77.5% (p<0.001). CTPA order rate and D-dimer order rate also increased significantly, from 17.1 to 18.4 per 1000 patients, p=0.035, and 30.6 to 37.3 per 1000 patients, p<0.001, respectively. Percent yield showed no significant change (12.3% pre- vs.10.8% post-intervention; p=0.173). SPC analysis showed sustained special-cause variation in the post-intervention period for guideline concordance and D-dimer order rates, temporary special-cause variation for CTPA order rates, and no special-cause variation for percent yield.
CONCLUSION: Our success in increasing guideline concordance demonstrates the efficacy of a mixed methods, human-centered approach to behavior change. Given that neither of the secondary outcomes improved, our results may demonstrate potential limitations to the guidelines directing the ordering of CTPA studies and/or D-dimer ordering.
PMID:37247831 | DOI:10.1016/j.jacr.2023.02.033
