BACKGROUND:Evidence-based guidelines advise excluding pulmonary embolism (PE) diagnosis using d-dimer in patients with a lower probability of PE. Emergency physicians frequently order computed tomography (CT) pulmonary angiography without d-dimer testing or when d-dimer is negative, which exposes patients to more risk than benefit. Our objective was to develop a conceptual framework explaining emergency physicians’ test choices for PE.
METHODS:We conducted a qualitative study using in-depth interviews of emergency physicians in Canada. A nonmedical researcher conducted in-person interviews. Participants described how they would test simulated patients with symptoms of possible PE, answered a knowledge test and were interviewed on barriers to using evidence-based PE tests.
RESULTS:We interviewed 63 emergency physicians from 9 hospitals in 5 cities, across 3 provinces. We identified 8 domains: anxiety with PE, barriers to using the evidence (time, knowledge and patient), divergent views on evidence-based PE testing, inherent Wells score problems, the drive to obtain CT rather than to diagnose PE, gestalt estimation artificially inflating PE probability, subjective reasoning and cognitive biases supporting deviation from evidence-based tests and use of evidence-based testing to rule out PE in patients who are very unlikely to have PE. Choices for PE testing were influenced by the disease, environment, test qualities, physician and probability of PE.
INTERPRETATION:Analysis of structured interviews with emergency physicians provided a conceptual framework to explain how these physicians use tests for suspected PE. The data suggest 8 domains to address when implementing an evidence-based protocol to investigate PE.Pulmonary embolism (PE) occurs when a blood clot lodges in the pulmonary arteries. If left untreated, the disorder can progress, causing worsening morbidity and may become fatal.
1 Because of the acute nature of this condition, many patients with PE present to the emergency department.Diagnosing and excluding PE using computed tomography pulmonary angiography (CTPA) alone can be problematic because of radiation exposure, anaphylaxis to contrast, misdiagnosis and “overdiagnosis” of inconsequential PE
2 (leading to unnecessary anticoagulation therapy and psychological distress
3). Choosing Wisely
4,5 and the guideline from the American College of Physicians
6 recommend the use of risk stratification tools, including the Pulmonary Embolism Rule-out Criteria (PERC) clinical decision rule,
7 the Wells score
8 and blood concentration of d-dimer. These tools use different predetermined diagnostic algorithms to indicate the need for CTPA.
8–11 Evidence-based guidelines discourage further testing in patients at lower risk who have normal d-dimer levels, where imaging can cause more harm than benefit.
12,13 However, many emergency physicians opt for CTPA as a stand-alone test for PE.
14–17It remains unclear why emergency physicians sometimes do not use validated diagnostic PE tools. Furthermore, implementation of computerized decision support systems has had little success in modifying this behaviour.
18,19 We sought to develop a conceptual framework to describe how Canadian emergency physicians test for PE, and to document the cognitive and contextual barriers to using existing evidence-based diagnostic PE pathways.
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