VTE Week | Why Clinicians Don’t Follow PE Decision Tools

Written by Bo Stubblefield

Spoon Feed
Use of evidence-based decision tools when evaluating a patient for acute pulmonary embolism (PE) are fraught with barriers at both the provider and organizational level. This study used implementation science methods to explore some of the barriers and facilitators to the uptake of these tools in clinical practice.

Why does this matter?
Over-testing and over-diagnosis of PE is a problem – increased cost, increased length of stay, ionizing radiation, contrast dye administration (1,2). False positives are reported to be as high as 10 to 26% (3-5). Prior efforts to implement evidence-based practices for PE risk-stratification have had little success (6). The Choosing Wisely campaign has attempted to mitigate this problem by discouraging use of CT Pulmonary Angiography (CTPA) in patients low pre-test probability for PE. An exploratory study was needed to achieve a broader understanding of the barriers and facilitators to the uptake of evidence-based practice and Westafer, et al came through with the goods.

This work is an ode to implementation science. Implementation science is used to assess barriers and facilitators to implementation of evidence-based practice and has been shown to increase use of evidence-based interventions in the ED (7,8). The authors used Consolidated Framework for Implementation Research (CFIR) and Theoretical Domains Framework (TDF) to explore provider decision-making in patients with suspected PE and to identify implementation strategies. It is the first time implementation science frameworks and methods have been applied to facilitate our understanding of the use of evidence-based tools in the diagnosis and risk stratification of PE.

Validated tools for the management of acute PE exist. Why can’t we just play by the rules?
This was a qualitative research study using semi-structured interviews with 23 ED providers, hospitalists, and primary care physicians at 12 academic and community hospitals in New England (USA). Median number of years in practice was 14. Most providers interviewed reported familiarity with some risk stratification tools, but they were not using them in the way they were designed to be used…

Several barriers and facilitators emerged:

Barriers
Barriers predominated at the provider level and were due to knowledge, belief about consequences (fear of missing a PE), and emotions. Providers reported more confidence in their gestalt than risk stratification tools, yet they perceived the gestalt component of the Wells’ Criteria as a limitation to the tool. Providers unknowingly misinterpreted the Wells’ cutoffs and the application of the D-dimer for patients with suspected PE. Further, even when a patient fell into a Wells’ low- or intermediate-risk group, providers reported they often did not trust a negative D-dimer, despite guideline recommendations. Unsurprisingly, decision tools like PERC that were objective* and binary with an unambiguous outcome were preferred.

Facilitators
Facilitators predominated at the institutional level. Providers reported that clear, accessible, easy-to-follow algorithms endorsed by their hospitals or groups would facilitate their use of evidence-based approaches. Providers felt this would grant perceived medico-legal protection and establish a cultural norm of practice. They also cited peer pressure as a root cause to motivate change in practice, superseding journal articles and formal CME.

Another Spoonful

• AEM Editor-in-Chief Pick of the month: Decision Rules May Be Great, But People are Crazy

• Article Review from Bond, et al. – Hot off the Press: Tell me How to Diagnose a PE

• Know Thy PE Clinical Decision Tools: PERC, Age-adjusted D-dimer, Wells’ Criteria for PE, Geneva Score, YEARS Algorithm, sPESI, Hestia Criteria

• SGEM Article Review

• LITFL Westafer talks EBM approaches to PE

Source
Provider Perspectives on the Use of Evidence-based Risk Stratification Tools in the Evaluation of Pulmonary Embolism: A Qualitative Study. Acad Emerg Med. 2020;27(6):447-456. doi:10.1111/acem.13908

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Works Cited

1. Kline JA, Mitchell AM, Kabrhel C, Richman PB, Courtney DM. Clinical criteria to prevent unnecessary diagnostic testing in emergency department patients with suspected pulmonary embolism. Journal of thrombosis and haemostasis : JTH 2004;2:1247-55.

2. American College of Emergency Physicians Clinical Policies Subcommittee on Thromboembolic D, Wolf SJ, Hahn SA, et al. Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients Presenting to the Emergency Department With Suspected Acute Venous Thromboembolic Disease. Annals of emergency medicine 2018;71:e59-e109.

3. Courtney DM, Miller C, Smithline H, Klekowski N, Hogg M, Kline JA. Prospective multicenter assessment of interobserver agreement for radiologist interpretation of multidetector computerized tomographic angiography for pulmonary embolism. Journal of thrombosis and haemostasis : JTH 2010;8:533-9.

4. Hutchinson BD, Navin P, Marom EM, Truong MT, Bruzzi JF. Overdiagnosis of Pulmonary Embolism by Pulmonary CT Angiography. AJR Am J Roentgenol 2015;205:271-7.

5. Kline JA, Hogg MM, Courtney DM, Miller CD, Jones AE, Smithline HA. D-dimer threshold increase with pretest probability unlikely for pulmonary embolism to decrease unnecessary computerized tomographic pulmonary angiography. Journal of thrombosis and haemostasis : JTH 2012;10:572-81.

6. Wang RC, Bent S, Weber E, Neilson J, Smith-Bindman R, Fahimi J. The Impact of Clinical Decision Rules on Computed Tomography Use and Yield for Pulmonary Embolism: A Systematic Review and Meta-analysis.
   Annals of emergency medicine 2016;67:693-701 e3.

7. Bosch M, McKenzie JE, Ponsford JL, et al. Evaluation of a targeted, theory-informed implementation intervention designed to increase uptake of emergency management recommendations regarding adult patients with mild traumatic brain injury: results of the NET cluster randomised trial. Implement Sci 2019;14:4.

8. Bauer MS, Damschroder L, Hagedorn H, Smith J, Kilbourne AM. An introduction to implementation science for the non-specialist. BMC Psychol 2015;3:32.

*Reviewed by Clay Smith – Even the “objective” PERC rule can’t be used unless the patient is gestalt low. You just can’t get past gestalt and clinical judgment when you work up possible PE.