RT Journal Article
SR Electronic
T1 Physician choices in pulmonary embolism testing
JF Canadian Medical Association Journal
JO CMAJ
FD Canadian Medical Association
SP E38
OP E46
DO 10.1503/cmaj.201639
VO 193
IS 2
A1 Sahar Zarabi
A1 Teresa M. Chan
A1 Mathew Mercuri
A1 Clive Kearon
A1 Michelle Turcotte
A1 Emily Grusko
A1 David Barbic
A1 Catherine Varner
A1 Eileen Bridges
A1 Reaves Houston
A1 Debra Eagles
A1 Kerstin de Wit
YR 2021
UL http://www.cmaj.ca/content/193/2/E38.abstract
AB BACKGROUND: Evidence-based guidelines advise excluding pulmonary embolism (PE) diagnosis using d-dimer in patients with a lower probability of PE. Emergency physicians frequently order computed tomography (CT) pulmonary angiography without d-dimer testing or when d-dimer is negative, which exposes patients to more risk than benefit. Our objective was to develop a conceptual framework explaining emergency physicians’ test choices for PE.METHODS: We conducted a qualitative study using in-depth interviews of emergency physicians in Canada. A nonmedical researcher conducted in-person interviews. Participants described how they would test simulated patients with symptoms of possible PE, answered a knowledge test and were interviewed on barriers to using evidence-based PE tests.RESULTS: We interviewed 63 emergency physicians from 9 hospitals in 5 cities, across 3 provinces. We identified 8 domains: anxiety with PE, barriers to using the evidence (time, knowledge and patient), divergent views on evidence-based PE testing, inherent Wells score problems, the drive to obtain CT rather than to diagnose PE, gestalt estimation artificially inflating PE probability, subjective reasoning and cognitive biases supporting deviation from evidence-based tests and use of evidence-based testing to rule out PE in patients who are very unlikely to have PE. Choices for PE testing were influenced by the disease, environment, test qualities, physician and probability of PE.INTERPRETATION: Analysis of structured interviews with emergency physicians provided a conceptual framework to explain how these physicians use tests for suspected PE. The data suggest 8 domains to address when implementing an evidence-based protocol to investigate PE.