Patient-Level, Institutional, and Temporal Variations in Use of Imaging Modalities to Confirm Pulmonary Embolism
Authors: Mehdipoor Ghazaleh , Jimenez David , Bertoletti Laurent , Fidalgo Ángeles , Sanchez Muñoz-Torrero Juan Francisco , Gonzalez-Martinez José Pedro , Blanco-Molina Ángeles , Ángel Aibar Miguel , Bonnefoy Pierre-Benoît , Khorasani Ramin , Prince Martin R. , Bikdeli Behnood , Monreal Manuel , Adarraga María Dolores , Agud María , Azcarate-Agüero Pedro , Aibar Jesús , Alfonso Joaquín , Amado Cristina , Ignacio Arcelus Juan , Ballaz Aitor , Barba Raquel , Barrón Cristina Barbagelata, Manuel , Barrón-Andrés Belén , Camon Ana María , Cañas Inmaculada , Criado Juan , Ancos Cristina de , Miguel Javier de , del Toro Jorge , Demelo-Rodríguez Pablo , Díaz-Pedroche Carmen , Díaz-Peromingo José Antonio , Díaz-Simón Raquel , Díez-Sierra Javier , Milagros Domínguez Irene , Escribano José Carlos , Farfán Ana Isabel , Fernández-Capitán Carmen , Fernández-Reyes José Luis , Flores Katia , Font Carme , Font Llorenç , Francisco Iria , Gabara Cristina , Galeano-Valle Francisco , Ángeles García María , García-Bragado Ferran , García-García María , García-Raso Aránzazu , Gavín-Blanco Olga , Gavín-Sebastián Olga , Carmen Gayol María , Gil-Díaz Aída , Gómez-Cuervo Covadonga , Grau Enric , Gutiérrez-Guisado Javier , Hernández-Blasco Luis , Iglesias Marina , Jara-Palomares Luis , Jesús Jaras María , Joya María Dolores , Jou Inés , Lacruz Beatriz , Lalueza Antonio , Lecumberri Ramón , Lima Jorge , Llamas Pilar , Luis Lobo José , López-Jiménez Luciano , López-Miguel Patricia , José López-Núñez Juan , López-Reyes Raquel , Bosco López-Sáez Juan , Alejandro Lorente Manuel , Lorenzo Alicia , Loring Mónica , Lumbierres Marina , Madridano Olga , Maestre Ana , Javier Marchena Pablo , Martín-Fernández Miguel , Miguel Martín-Guerra Javier , Martín-Martos Francisco , Mellado Meritxel , Mercado María Isabel , Moisés Jorge , del Valle Morales María , Muñoz-Blanco Arturo , Muñoz-Guglielmetti Diego , Antonio Nieto José , Jesús Núñez Manuel , Ortega-Michel María Carmen Olivares, Clara , Dolores Ortega-Recio María , Osorio Jeisson , Otero Remedios , Paredes Diana , Parra Pedro , Parra Virginia , Pedrajas José María , Pellejero Galadriel , Pérez-Ductor Cristina , Asunción Pérez-Jacoíste María , Pesántez David , Porras José Antonio , Portillo José , Reig Lluis , Riera-Mestre Antoni , Rivas Agustina , Rodríguez-Cobo Ana , Rodríguez-Galán Irene , Rodríguez-Matute Consolación , Rosa Vladimir , María Rubio Carmen , Ruiz-Artacho Pedro , Ruiz-Giménez Nuria , Ruiz-Ruiz Justo , Ruiz-Sada Pablo , Ruiz-Torregrosa Paloma , Carles Sahuquillo Joan , Salgueiro Giorgina , Sampériz Ángel , Sancho Teresa , Soler Silvia , Suárez Susana , María Suriñach José , Tiberio Gregorio , Isabel Torres María , Tolosa Carlos , Trujillo-Santos Javier , Uresandi Fernando , Usandizaga Esther , Valle Reina , Ramón Vela Jeronimo , Vidal Gemma , Villares Paula , Zamora Carles , Gutiérrez Paula , Javier Vázquez Fernando , Vanassche Thomas , Vandenbriele Christophe , Verhamme Peter , Hirmerova Jana , Malý Radovan , Salgado Estuardo , Benzidia Ilham , Bura-Riviere Alessandra , Crichi Benjamin , Debourdeau Philippe , Farge-Bancel Dominique , Helfer Hélène , Mahé Isabelle , Moustafa Farès , Poenou Geraldine , Schellong Sebastian , Braester Andrei , Brenner Benjamin , Tzoran Inna , Amitrano María , Bilora Franca , Bortoluzzi Cristiano , Brandolin Barbara , Bucherini Eugenio , Ciammaichella Maurizio , Colaizzo Donatella , Dentali Francesco , Micco Pierpaolo Di , Giammarino Eliana , Grandone Elvira , Maggi Fabio , Mangiacapra Sara , Mastroiacovo Daniela , Maida Rosa , Pace Federica , Pesavento Raffaele , Pomero Fulvio , Prandoni Paolo , Quintavalla Roberto , Rocci Anna , Siniscalchi Carmine , Tiraferri Eros , Tufano Antonella , Visonà Adriana , Hong Ngoc Vo , Zalunardo Beniamino , Kalejs Roberts V. , Kigitovica Dana , Skride Andris , Ferreira Melanie , Meireles Jose , Reis Abilio , Bosevski Marijan , Krstevski Gorjan , Zdraveska Marija , Bounameaux Henri , Mazzolai Lucia , Caprini Joseph A. , Tafur Alfonso J. , Weinberg Ido , Wilkins Hannah , My Bui Hanh 
Published: May 2020

Background:
The choice of the imaging modality for diagnosis of pulmonary embolism (PE) could be influenced by provider, patient or hospital characteristics, or over time. However, little is known about the choice of the diagnostic modalities in practice. The aim of this study was to evaluate the variations in the use of imaging modalities for patients with acute PE.

Methods:
Using the data from Registro Informatizado Enfermedad TromboEmbolica (RIETE), a prospective international registry of patients with venous thromboembolism (March 2001–January 2019), we explored the imaging modalities used in patients with acute PE. The imaging modalities included computed tomography pulmonary angiography, ventilation/perfusion scanning, pulmonary angiography, a combination of these tests, or PE signs and symptoms plus imaging-confirmed proximal deep vein thrombosis but no chest imaging.

Results:

Among 38 025 patients with confirmed PE (53.1% female, age: 67.3±17 years), computed tomography pulmonary angiography was the dominant modality of diagnosis in all RIETE enrollees (78.2% [99% CI, 77.6–78.7]); including pregnant patients (58.9% [99% CI, 47.7%–69.4%]) and patients with severe renal insufficiency (62.5% [99% CI, 59.9–65.0]). A greater proportion of patients underwent ventilation/perfusion scanning in larger hospitals compared with smaller hospitals (13.1% versus 7.3%,
P
<0.001). The use of computed tomography pulmonary angiography varied between 13.3% and 98.3% across the countries, and its use increased over time (46.5% in 2002 to 91.7% in 2018,
P
<0.001).

Conclusions:
In a large multinational PE registry, variations were observed in the use of imaging modalities according to patient or institutional factors and over time. However, computed tomography pulmonary angiography was the dominant modality of diagnosis, even in pregnancy and severe renal insufficiency. The safety, costs, and downstream effects of these tests on PE-related and non-PE-related outcomes warrant further investigation.