CTA chest use in ED to fish for PEs Samiya Hussain, DSR2 Cost Conscious Care presentation

Best Practice advice from clinical guidelines committee of ACP to evaluate suspected PE Clinicians should use validated clinical prediction rules to estimate pretest probability in patients in whom acute PE is being considered. Clinicians should not obtain d-dimer measurements or imaging studies in patients with a low pretest probability of PE and who meet all Pulmonary Embolism Rule-Out Criteria (PEROC). Clinicians should obtain a high-sensitivity d-dimer measurement as the initial diagnostic test in patients who have an intermediate pretest probability of PE or in patients with low pretest probability of PE who do not meet all Pulmonary Embolism Rule-Out Criteria. Clinicians should not use imaging studies as the initial test in patients who have a low or intermediate pretest probability of PE. Raja AS, Greenberg JO, Qaseem A, Denberg TD, Fitterman N, Schuur JD, et al. Evaluation of Patients With Suspected Acute Pulmonary Embolism: Best Practice Advice From the Clinical Guidelines Committee of the American College of Physicians. Ann Intern Med. ;163:701–711. doi: 10.7326/M14-1772

Best Practice advice from clinical guidelines committee of ACP to evaluate suspected PE cont’d 4. Clinicians should use age-adjusted d-dimer thresholds (age × 10 ng/mL rather than a generic 500 ng/mL) in patients older than 50 years to determine whether imaging is warranted. 5. Clinicians should not obtain any imaging studies in patients with a d-dimer level below the age-adjusted cutoff. 6. Clinicians should obtain imaging with CT pulmonary angiography (CTPA) in patients with high pretest probability of PE. Clinicians should reserve ventilation–perfusion scans for patients who have a contraindication to CTPA or if CTPA is not available. Clinicians should not obtain a d-dimer measurement in patients with a high pretest probability of PE. Raja AS, Greenberg JO, Qaseem A, Denberg TD, Fitterman N, Schuur JD, et al. Evaluation of Patients With Suspected Acute Pulmonary Embolism: Best Practice Advice From the Clinical Guidelines Committee of the American College of Physicians. Ann Intern Med. ;163:701–711. doi: 10.7326/M14-1772

Why are guidelines and/or recommendations important? Test Rough cost at UCI D-dimer $68-87 CTA chest $2,059 DVT ultrasound $1,136 V/Q scan $1,333

Data collection Using the ED board, 32 patients were identified as being tested for ddimer with 25 of these having a CTA chest ordered as well. Chart review was performed to help understand if the tests were appropriate.

Data analysis Chief complaint resulting in D-dimer testing Chest pain Shortness of breath Fever Mechanical Fall Cough Melena Fatigue Altered mental status Abdominal pain Pretest probability D-dimer CTA Low - Meets PEROC 16 9 - doesn’t meet PEROC 12 Intermediate 4 High None N/a Could have avoided 9 x (2059) + 68 x (16) = $ 19,619 being spent on patients for screening with Ddimer/CTA when not indicated - 19, 619 x 30 =$ 588, 570/month - 19, 619 x 365 = $7,160,935/year

Key points to avoid unnecessary costs while fishing for PEs Key clinical factors Educate staff on cost Seminar/series of costs of tests Mandatory training online to visualize the basic costs for most ordered by each speciality Use decision tools Well’s criteria (original, dichotomized, simplified) Geneva score (revised and simple) Raja AS, Greenberg JO, Qaseem A, Denberg TD, Fitterman N, Schuur JD, et al. Evaluation of Patients With Suspected Acute Pulmonary Embolism: Best Practice Advice From the Clinical Guidelines Committee of the American College of Physicians. Ann Intern Med. ;163:701–711. doi: 10.7326/M14-1772

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