Almost no hospitals in the California Veteran's Administration system adhere to national guidelines that recommend the use of a clinical decision rule and D-dimer test before patients with pulmonary embolism are referred for CT pulmonary angiography.
This widespread lack of adherence puts far too many patients at risk for potential complications from CT, including radiation-induced cancer, contrast-mediated complications, and haemorrhage if patients are subsequently given anticoagulants for lesions that do not require treatment.
The clinical decision rule and D-dimer test should be used for "100% of individuals" before a CT pulmonary angiography is ordered, In accordance with international guidelines,
The indiscriminate use of CT pulmonary angiography only serves to expose patients to unnecessary test- and treatment-related consequences.
We sent out a web-based questionnaire querying whether they were using the clinical decision rule, the D-dimer, or both for the evaluation of suspected pulmonary embolism," We assumed that the key stakeholders would be chiefs of the pulmonary, radiology, and emergency medicine departments.
The team used geographic administrative areas, known as Veterans Integrated Service Network (VISN), to collect data so that individual hospitals were not identified.
The 120 responses available for analysis came from chiefs of their respective departments with at least 11 years of clinical experience, and the three main specialties were fairly evenly represented.
At the level of the VISN, we found a very small minority of geographic regions containing even one hospital that adhered to the guidelines.
Overall, 93% of respondents said that no clinical decision rule is required before a patient is referred for a CT pulmonary angiography at their hospitals, and 89% said that D-dimer testing is not required.
If a patient has a clot, the D-dimer test should be able to detect its breakdown products, Only 6.7% of respondents reported that both the clinical decision rule and D-dimer test are required at their hospitals before a patient is referred for CT pulmonary angiography,
5.8% reported that the decision rule is required, and 2.5% reported that the D-dimer is required. There was a trend suggesting that the use of the clinical decision rule, the D-dimer test, or both before angiography might boost the yield in terms of identifying pulmonary embolism on subsequent CT pulmonary angiography.