Response by Kline to Letter Regarding Article, “Over-Testing for Suspected Pulmonary Embolism in American Emergency Departments: The Continuing Epidemic” (2020)

HomeCirculation: Cardiovascular Quality and OutcomesVol. 13, No. 4Response by Kline to Letter Regarding Article, "Over-Testing for Suspected Pulmonary Embolism in American Emergency Departments: The Continuing Epidemic" Free AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessLetterPDF/EPUBResponse by Kline to Letter Regarding Article, "Over-Testing for Suspected Pulmonary Embolism in American Emergency Departments: The Continuing Epidemic" Jeffrey Kline, MD Jeffrey KlineJeffrey Kline Indiana University School of Medicine, Indianapolis. Originally published1 Apr 2020https://doi.org/10.1161/CIRCOUTCOMES.120.006588Circulation: Cardiovascular Quality and Outcomes. 2020;13:e006588Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: April 1, 2020: Ahead of Print In Response:Consistent with the points raised by Priya et al, our data showed significant differences in the yield rate of pulmonary embolism (PE) on computerized tomographic pulmonary angiography (CTPA) between Indiana and the Dallas-Fort Worth samples. We agree with the authors, based upon nothing more than common sense, that the yield rate for PE on CTPA should be near 10%. Yet this yield rate appears closer to 3% to 4% in large samples of patients undergoing CTPA in the United States, including ours.1,2Causes of regional differences in PE yield rate on CTPA remain vague. We speculate that differences in testing threshold may vary with provider perceptions of local normative behavior,3 provider perceptions of patient preferences,4 regional perception of medical malpractice risk,5,6 and the result of actual interventions by practice administrators to increase the use of pretest probability assessment linked to D-dimer testing. We think the latter reason is the most likely explanation for why our Dallas-Fort Worth sample had a higher yield rate.Methods of extracting PE diagnosis from International Classification of Disease (ICD) coding could influence the apparent yield rate as well.7 We have found that ICD coding is unreliable unless PE is the first-coded ICD diagnosis. In random audits of charts, we have found that often, coders carry over a prior ICD diagnosis of PE, including it in a list of other prior diagnoses. If the ICD search is not specific for PE as the first in the list, often the finding of an ICD for PE does not represent a new diagnosis.Undoubtably, emergency provider threshold for ordering CTPA varies by site, and it appears from our data that wider use of the D-dimer helps to reduce low-value CTPA imaging.Sources of FundingThis work was supported by the Eli Lilly Foundation Physician Scientist Initiative.DisclosuresThe author's institution has received money from Stago Diagnostica for a research contract.References1. Feng LB, Pines JM, Yusuf HR, Grosse SD. U.S. trends in computed tomography use and diagnoses in emergency department visits by patients with symptoms suggestive of pulmonary embolism, 2001-2009.Acad Emerg Med. 2013; 20:1033–1040. doi: 10.1111/acem.12221CrossrefMedlineGoogle Scholar2. Kline JA, Garrett JS, Sarmiento EJ, Strachan CC, Courtney DM. Over-testing for suspected pulmonary embolism in American Emergency Departments: the continuing epidemic.Circ Cardiovasc Qual Outcomes. 2020; 13:e005753. doi: 10.1161/CIRCOUTCOMES.119.005753LinkGoogle Scholar3. Lucas FL, Sirovich BE, Gallagher PM, Siewers AE, Wennberg DE. Variation in cardiologists' propensity to test and treat: is it associated with regional variation in utilization?Circ Cardiovasc Qual Outcomes. 2010; 3:253–260. doi: 10.1161/CIRCOUTCOMES.108.840009LinkGoogle Scholar4. Geyer BC, Xu M, Kabrhel C. Patient preferences for testing for pulmonary embolism in the ED using a shared decision-making model.Am J Emerg Med. 2014; 32:233–236. doi: 10.1016/j.ajem.2013.11.019CrossrefMedlineGoogle Scholar5. Kanzaria HK, Hoffman JR, Probst MA, Caloyeras JP, Berry SH, Brook RH. Emergency physician perceptions of medically unnecessary advanced diagnostic imaging.Acad Emerg Med. 2015; 22:390–398. doi: 10.1111/acem.12625CrossrefMedlineGoogle Scholar6. Li S, Brantley E. Malpractice liability risk and use of diagnostic imaging services: a systematic review of the literature.J Am Coll Radiol. 2015; 12(12pt B):1403–1412. doi: 10.1016/j.jacr.2015.09.015CrossrefMedlineGoogle Scholar7. Burles K, Innes G, Senior K, Lang E, McRae A. Limitations of pulmonary embolism ICD-10 codes in emergency department administrative data: let the buyer beware.BMC Med Res Methodol. 2017; 17:89. doi: 10.1186/s12874-017-0361-1CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetails April 2020Vol 13, Issue 4 Advertisement Article InformationMetrics © 2020 American Heart Association, Inc.https://doi.org/10.1161/CIRCOUTCOMES.120.006588PMID: 32233653 Originally publishedApril 1, 2020 PDF download Advertisement SubjectsComputerized Tomography (CT)Diagnostic Testing