Appropriateness of PE workup at UCI based on Well’s Criteria Amy Ni, MD Cost Consciousness Project: March 2015

PE PE workup usually begun in the ED; other times started on the floor PE workup usually begun in the ED; other times started on the floor Previous large power studies have shown that only about 10% of CT angiograms ordered to rule out PE is actually positive Previous large power studies have shown that only about 10% of CT angiograms ordered to rule out PE is actually positive Radiology Aug;256(2): Radiology Aug;256(2): Therefore the appropriateness of using tests such as d-dimer, lower extremity ultrasound, and CT angiogram in setting of PE diagnosis is questionable Therefore the appropriateness of using tests such as d-dimer, lower extremity ultrasound, and CT angiogram in setting of PE diagnosis is questionable

Question Do UCI clinicians follow the Well’s criteria of pre- test probability for ordering studies to rule out PE? Do UCI clinicians follow the Well’s criteria of pre- test probability for ordering studies to rule out PE?

Past Project Previous cost consciousness project (22 cases) showed only 9% CT angiograms ordered showed PE; correlated with large published studies Previous cost consciousness project (22 cases) showed only 9% CT angiograms ordered showed PE; correlated with large published studies Only two d-dimers were checked: one positive in setting of PE and one negative in setting of negative CTA Only two d-dimers were checked: one positive in setting of PE and one negative in setting of negative CTA Lower extremity ultrasound performed in only 4 patients (18%); one had DVT and PE Lower extremity ultrasound performed in only 4 patients (18%); one had DVT and PE 20% had Well’s >4; 80% score 4; 80% score <4, 50% score <2 Are we doing any better now?? Are we doing any better now??

My Project Chart review of UCI Medical Center via Quest EMR of patients presenting in the ED, admitted to medicine floor teams and family medicine teams Chart review of UCI Medical Center via Quest EMR of patients presenting in the ED, admitted to medicine floor teams and family medicine teams Patients presenting with CC of chest pain, shortness of breath, lower extremity swelling, hypoxia Patients presenting with CC of chest pain, shortness of breath, lower extremity swelling, hypoxia Analysis of 12 random patients from 3/7/15 to 3/15/15 with the above chief complaints Analysis of 12 random patients from 3/7/15 to 3/15/15 with the above chief complaints Well’s score calculated and appropriateness of workup determined Well’s score calculated and appropriateness of workup determined

Well’s Score

Results 8 ED cases; 2 medicine cases, 2 family medicine cases 8 ED cases; 2 medicine cases, 2 family medicine cases Only 66.7% (8 cases out of 12) where d-dimer was appropriately ordered or not ordered Only 66.7% (8 cases out of 12) where d-dimer was appropriately ordered or not ordered Only 28% of lower extremity ultrasounds ordered was positive; 1 was entirely incidental Only 28% of lower extremity ultrasounds ordered was positive; 1 was entirely incidental 6/12 cases progressed to ordering CTA; out of the 6 only 1 was positive for PE (16.6%); 4/6 CTA was part of appropriate workup per Well’s 6/12 cases progressed to ordering CTA; out of the 6 only 1 was positive for PE (16.6%); 4/6 CTA was part of appropriate workup per Well’s 50% of cases were appropriately worked up per Well’s criteria 50% of cases were appropriately worked up per Well’s criteria

Cost A quick search online estimates the cost of CT angiogram to the patient ranging from $700 to $1500. Therefore extrapolate an average of $1100 per CT angiogram. A quick search online estimates the cost of CT angiogram to the patient ranging from $700 to $1500. Therefore extrapolate an average of $1100 per CT angiogram. My study shows out of the 6 CT angiograms ordered, 2 were not appropriately ordered My study shows out of the 6 CT angiograms ordered, 2 were not appropriately ordered Therefore this is an estimated 33% misuse of CT angiograms, costing about $2200 Therefore this is an estimated 33% misuse of CT angiograms, costing about $2200 $2200 of inappropriately ordered CTA in 1 week extrapolates to $114,400 of potential savings in one year for the patient if clinicians would follow Well’s criteria $2200 of inappropriately ordered CTA in 1 week extrapolates to $114,400 of potential savings in one year for the patient if clinicians would follow Well’s criteria

Conclusions We are still not doing well in terms of appropriate PE workup per Well’s criteria We are still not doing well in terms of appropriate PE workup per Well’s criteria Only 50% of cases were worked up appropriately Only 50% of cases were worked up appropriately Documentation needs to include reasons for ordering a test, in a evidence based manner Documentation needs to include reasons for ordering a test, in a evidence based manner The one case of actual PE had Well’s score of 4.5, which can be interpreted as moderate probability The one case of actual PE had Well’s score of 4.5, which can be interpreted as moderate probability Higher rate of PE on CTA likely due to low power of the study Higher rate of PE on CTA likely due to low power of the study This shows that at the end of the day it is still a clinical guideline; use carefully in each scenario This shows that at the end of the day it is still a clinical guideline; use carefully in each scenario