Scott Aaron Atkins MD, Presenter: Nothing to Disclose

Steven Munson MD, Abstract Co-Author: Nothing to Disclose

J. Paul Jacobson MD, Abstract Co-Author: Stockholder, Genelux Corporation

Thomas J. Kelly MD, Abstract Co-Author: Nothing to Disclose

A recent study has shown that approximately one third of CT pulmonary angiograms (CTPAs) performed to rule out pulmonary embolism (PE) in the emergency department (ED) are in low risk or very low risk patients based on Wells criteria and D-dimer, resulting in potentially avoidable cost to our healthcare system and risk to patients. The purpose of this study is to evaluate the cost effectiveness of CTPA in diagnosing PE in low risk patients and to quantify potentially avoidable cost and patient risk with the current medical practice pattern. Other studies have been done showing that CTPA is a cost effective method to diagnose PE when used in conjunction with Wells criteria and D-dimer. However, no studies have quantified the additional cost and patient risk when this standard of care is not followed and potentially avoidable imaging is performed.

A literature search was performed and data on the current use of CTPA in the diagnosis of PE was reviewed. A decision model was constructed for evaluating low and very low risk patients for PE with and without the use of CTPA. The costs and patient utilities for each outcome were plotted to determine the dominant strategy. Strategies are dominant if they have lower costs and better outcomes compared to other strategies based on quality adjusted life years (QALYs). Sensitivity analyses were performed to test the stability of the results over a wide range of clinically relevant values.

The strategy of ED observation, not performing CTPA, dominated the strategy of performing CTPA to rule out PE in low and very low risk ED patients. ED observation dominated over a wide range of clinically relevant values, showing cost savings to the medical system and better patient outcomes when compared to performing CTPA in this population.

Ruling out pulmonary embolism in ED patients should begin with an assessment of risk based on clinical factors (Wells criteria) and a D-dimer to ensure that CTPA is not performed on patients who are low or very low risk. The potentially avoidable CTPAs performed on low risk patients add significant cost to the medical system without improving patient care. In fact, potentially avoidable imaging poses significant risk to these patients.

Performing CTPA to rule out PE in low and very low risk ED patients increases medical costs and increases patient risk, worsening patient outcomes.

Atkins, S, Munson, S, Jacobson, J, Kelly, T, Cost and Risk Analysis of CT Pulmonary Angiography to Rule Out Pulmonary Embolism in Low and Very Low Risk Emergency Department Patients.  Radiological Society of North America 2013 Scientific Assembly and Annual Meeting, December 1 - December 6, 2013 ,Chicago IL. http://archive.rsna.org/2013/13019158.html