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60 Temporal Trends in the Use of Computed Tomographic Pulmonary Angiography for Suspected Pulmonary Embolism in the Emergency Department

2022; Elsevier BV; Volume: 80; Issue: 4 Linguagem: Inglês

10.1016/j.annemergmed.2022.08.083

1097-6760

Mélanie Roussel, A. Aparicio-Montforte, W Hayman Behringer, O. Hugli, A. Marra, A. Penaloza, C. Choquet, D. Douillet, B. Bloom, Y. Freund,

Venous Thromboembolism Diagnosis and Management

BackgroundIn recent years, several clinical decision rules, including age-adjusted D-dimer threshold, PERC, YEARS, and PEGeD, have been derived to safely limit the use of computed tomographic pulmonary angiography (CTPA) in patients with suspected pulmonary embolism (PE) in the emergency department (ED). The hypothesis of this study is that this has led to a subsequent reduction in CTPA use.ObjectivesTo evaluate the temporal trend of CTPA use for suspected PE between 2015 and 2020. Method: This was a retrospective multicenter time series analysis of 26 European EDs in 6 countries. All CTPA performed for suspected PE in the ED during the first 7 days of each odd month between January 2015 and December 2019 inclusive were included (ie a total of 30 7-day periods). The primary endpoint was the number of CTPA performed in each period per 100 000 ED visits/year. Secondary endpoints included the diagnosis of PE, the size of PE diagnosed, in- or out-patient management of PE, and CTPA yield. The endpoints were analyzed using linear regression and confirmed with mixed generalized linear models (MGLM) and Seasonal Autoregressive Integrated Moving Average (SARIMA) models.Results8707 CTPA were included (median age 64 [47; 76] years, 56% female). According to the revised Geneva score, the clinical probability of PE was low for 2225 (26%) patients, intermediate for 5808 (67%) patients, and high for 674 (8%) patients. Overall, a mean of 11 CTPA were performed each week during the study period, and 1413 (16.4%) patients had a PE. The mean number of CTPA per week increased from 9 in 2015 to 12 in 2019. The number of CTPA per 100,000 visits/year increased with a statistically significant annual increase of 41 (95% CI 11 to 70, p=0.01) (Figure 1). Both the MGLM and SARIMA techniques confirmed the significant trend, with annual increases of 41 (95% CI 18 to 64, p=0.001) and 54 (95% CI 91 to 178, p=0.01) CTPA per 100,000 visits/year for the MGLM and SARIMA models respectively. During the study period, there was also an increased number of PE diagnosed per 100,000 visits/year (138 in 2015 and 163 in 2019, significant annual increase 7 [95% CI 1 to 13], p=0.033). The CTPA positive rate remained stable over time (17%). The number of PE that were treated with outpatient management increased from 18 in 2015 to 28 in 2019 (significant annual increase 2 [95% CI 0 to 3], p=0.004). All significant trends were confirmed through further analyses, using MGLM and SARIMA models. Of note, the SARIMA model showed a seasonality in CTPA use, with greater usage during winter.ConclusionIn this retrospective study of 26 European EDs, the number of CTPA performed for suspected PE has significantly increased between 2015 and 2020, with a concurrent increase in the number of PEs diagnosed, and a stable diagnostic yield.No, authors do not have interests to disclose BackgroundIn recent years, several clinical decision rules, including age-adjusted D-dimer threshold, PERC, YEARS, and PEGeD, have been derived to safely limit the use of computed tomographic pulmonary angiography (CTPA) in patients with suspected pulmonary embolism (PE) in the emergency department (ED). The hypothesis of this study is that this has led to a subsequent reduction in CTPA use. In recent years, several clinical decision rules, including age-adjusted D-dimer threshold, PERC, YEARS, and PEGeD, have been derived to safely limit the use of computed tomographic pulmonary angiography (CTPA) in patients with suspected pulmonary embolism (PE) in the emergency department (ED). The hypothesis of this study is that this has led to a subsequent reduction in CTPA use. ObjectivesTo evaluate the temporal trend of CTPA use for suspected PE between 2015 and 2020. Method: This was a retrospective multicenter time series analysis of 26 European EDs in 6 countries. All CTPA performed for suspected PE in the ED during the first 7 days of each odd month between January 2015 and December 2019 inclusive were included (ie a total of 30 7-day periods). The primary endpoint was the number of CTPA performed in each period per 100 000 ED visits/year. Secondary endpoints included the diagnosis of PE, the size of PE diagnosed, in- or out-patient management of PE, and CTPA yield. The endpoints were analyzed using linear regression and confirmed with mixed generalized linear models (MGLM) and Seasonal Autoregressive Integrated Moving Average (SARIMA) models. To evaluate the temporal trend of CTPA use for suspected PE between 2015 and 2020. Method: This was a retrospective multicenter time series analysis of 26 European EDs in 6 countries. All CTPA performed for suspected PE in the ED during the first 7 days of each odd month between January 2015 and December 2019 inclusive were included (ie a total of 30 7-day periods). The primary endpoint was the number of CTPA performed in each period per 100 000 ED visits/year. Secondary endpoints included the diagnosis of PE, the size of PE diagnosed, in- or out-patient management of PE, and CTPA yield. The endpoints were analyzed using linear regression and confirmed with mixed generalized linear models (MGLM) and Seasonal Autoregressive Integrated Moving Average (SARIMA) models. Results8707 CTPA were included (median age 64 [47; 76] years, 56% female). According to the revised Geneva score, the clinical probability of PE was low for 2225 (26%) patients, intermediate for 5808 (67%) patients, and high for 674 (8%) patients. Overall, a mean of 11 CTPA were performed each week during the study period, and 1413 (16.4%) patients had a PE. The mean number of CTPA per week increased from 9 in 2015 to 12 in 2019. The number of CTPA per 100,000 visits/year increased with a statistically significant annual increase of 41 (95% CI 11 to 70, p=0.01) (Figure 1). Both the MGLM and SARIMA techniques confirmed the significant trend, with annual increases of 41 (95% CI 18 to 64, p=0.001) and 54 (95% CI 91 to 178, p=0.01) CTPA per 100,000 visits/year for the MGLM and SARIMA models respectively. During the study period, there was also an increased number of PE diagnosed per 100,000 visits/year (138 in 2015 and 163 in 2019, significant annual increase 7 [95% CI 1 to 13], p=0.033). The CTPA positive rate remained stable over time (17%). The number of PE that were treated with outpatient management increased from 18 in 2015 to 28 in 2019 (significant annual increase 2 [95% CI 0 to 3], p=0.004). All significant trends were confirmed through further analyses, using MGLM and SARIMA models. Of note, the SARIMA model showed a seasonality in CTPA use, with greater usage during winter. 8707 CTPA were included (median age 64 [47; 76] years, 56% female). According to the revised Geneva score, the clinical probability of PE was low for 2225 (26%) patients, intermediate for 5808 (67%) patients, and high for 674 (8%) patients. Overall, a mean of 11 CTPA were performed each week during the study period, and 1413 (16.4%) patients had a PE. The mean number of CTPA per week increased from 9 in 2015 to 12 in 2019. The number of CTPA per 100,000 visits/year increased with a statistically significant annual increase of 41 (95% CI 11 to 70, p=0.01) (Figure 1). Both the MGLM and SARIMA techniques confirmed the significant trend, with annual increases of 41 (95% CI 18 to 64, p=0.001) and 54 (95% CI 91 to 178, p=0.01) CTPA per 100,000 visits/year for the MGLM and SARIMA models respectively. During the study period, there was also an increased number of PE diagnosed per 100,000 visits/year (138 in 2015 and 163 in 2019, significant annual increase 7 [95% CI 1 to 13], p=0.033). The CTPA positive rate remained stable over time (17%). The number of PE that were treated with outpatient management increased from 18 in 2015 to 28 in 2019 (significant annual increase 2 [95% CI 0 to 3], p=0.004). All significant trends were confirmed through further analyses, using MGLM and SARIMA models. Of note, the SARIMA model showed a seasonality in CTPA use, with greater usage during winter. ConclusionIn this retrospective study of 26 European EDs, the number of CTPA performed for suspected PE has significantly increased between 2015 and 2020, with a concurrent increase in the number of PEs diagnosed, and a stable diagnostic yield.No, authors do not have interests to disclose In this retrospective study of 26 European EDs, the number of CTPA performed for suspected PE has significantly increased between 2015 and 2020, with a concurrent increase in the number of PEs diagnosed, and a stable diagnostic yield.