The patterns of ordering Computed Tomography Pulmonary Angiogram (CTPA) for diagnosis of pulmonary embolism (PE) in a rural health setting

Alshehri Am, Srinivasan, Umair Khan, S. Wickremasena, Hui Jh, Lee Gs, A. Bhattacharya
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Result: A total of 249 CTPAs were done during this study period. In term of patient demographics, median age was 63 years and 48.6 % of patients were females. PE was diagnosed in 34 (13.7%) patients. Only 196 (76.6%) patients had a CXR as an initial investigation. Acute kidney injury was noted in 23 (14.0%) patients post CTPA. Revised Geneva score was calculated for all patients who had CTP for PE, only 10 (4 %) patients had a high probability on Revised Geneva score (score >11). Wells score could not be accurately calculated due to the retrospective nature of the study. Conclusion: The diagnostic yield of CTPA with a positive result for pulmonary embolism was 13.7%, which is below the recommended standards by the Royal College of Radiology (UK) (15.4% to 37.4%). Also, these findings were noted to be inferior compared with a similar study done in an Australian hospital. These findings may be attributed to the poor utilization of risk assessment tools (Geneva, Wells and D-Dimer) and not performing simple chest X-ray prior to CTPA. A protocol to request CTPAs is needed which is suited to the regional settings to avoid unnecessary CTPAs and its complications. Correspondence to: Al Alawi AM, Department of Medicine, Goulburn Valley Health, Australia, E-mail: dr.abdullahalalawi@gmail.com Received: March 03, 2018; Accepted: March 20, 2018; Published: March 24, 2018 Introduction Pulmonary embolism (PE) is a potentially fatal condition if left untreated. The annual crude incidence rate of PE in Australian was estimated to be 0.31 per 1000 in a community setting [1]. The 1-year case-fatality rate for PE is approximately 23% [2]. Efficient clinical evaluation and diagnostic testing is necessary to avoid delays in initiating therapy, which in turn reduces morbidity and mortality from PE [3]. Pulmonary angiography is the historical criterion standard for the diagnosis of PE, which has now been largely replaced by less invasive alternatives. CTPA is the investigation of choice for diagnosis of PE but requires the use of potentially nephrotoxic contrast agents and radiation [4,5]. Alternatively, as a result V/Q scans are commonly considered in patients with renal impairment, pregnant women and in young patients due to the lower dose of radiation [6]. Over the last decade, there has been a significant increase in CTPA use for diagnosis of PE [7]. Inappropriate CTPA use is associated with increases in health care expenditure and risks causing unnecessary harm for patient such as contrast-induced nephropathy and hypersensitivity reactions [8]. The positive rate of CTPA for PE can be as low as 7% but this rate can be increased to more than 30% with use of pre-test risk assessment tools [9-11]. Commonly applied stratifying tools are the Wells score and the revised Geneva score [12]. Depending on the risk factors for pulmonary embolism, patients are categorized into three groups: low (Geneva score 0–3, Wells score 0–1), intermediate (Geneva score 4–10, Wells score 2–6) or high (Geneva score ≥11, Wells score ≥7) [13]. The D-Dimer value is a very useful marker in low/intermediate probability groups and its use has been validated in several studies [12]. In the general population, the combination of D-Dimer testing and clinical assessment tools miss less than 2% of PEs [14]. Objectives of the study The objectives of this audit are: 1)To evaluate the appropriate use of CTPA (overuse/underuse) and the rate of positive results of CTPA for PE in a regional health setting. 2)To check the degree of adherence to an existing algorithm for using CTPA for PE. 3)To estimate the rate of contrast induced nephropathy. Al Alawi AM (2018) The patterns of ordering Computed Tomography Pulmonary Angiogram (CTPA) for diagnosis of pulmonary embolism (PE) in a rural health setting Volume 2(2): 2-3 Radiol Diagn Imaging, 2018 doi: 10.15761/RDI.1000127 Setting Goulburn Valley Health is a rural hospital located 200km northeast of Melbourne that provides care for a catchment population of approximately 120,000 people from the City of Greater Shepparton extending to southern New South Wales. 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Abstract

Background: Pulmonary embolism (PE) is a life-threatening condition with overall mortality of up to 20 % when left untreated. CTPA is the preferred investigation for diagnosis of PE for patients with normal kidney function. Several studies showed this test is being over employed without using available predictive tools i.e. Wells score, Modified Geneva score & D-Dimer Methodology: A retrospective review of patients’ records who had CTPA for suspected pulmonary embolism from the period of 1st March 2015 to 28th Feb 2016. Patient’s demographics and components of different scoring system were obtained by manual review of patient’s electronic records. Result: A total of 249 CTPAs were done during this study period. In term of patient demographics, median age was 63 years and 48.6 % of patients were females. PE was diagnosed in 34 (13.7%) patients. Only 196 (76.6%) patients had a CXR as an initial investigation. Acute kidney injury was noted in 23 (14.0%) patients post CTPA. Revised Geneva score was calculated for all patients who had CTP for PE, only 10 (4 %) patients had a high probability on Revised Geneva score (score >11). Wells score could not be accurately calculated due to the retrospective nature of the study. Conclusion: The diagnostic yield of CTPA with a positive result for pulmonary embolism was 13.7%, which is below the recommended standards by the Royal College of Radiology (UK) (15.4% to 37.4%). Also, these findings were noted to be inferior compared with a similar study done in an Australian hospital. These findings may be attributed to the poor utilization of risk assessment tools (Geneva, Wells and D-Dimer) and not performing simple chest X-ray prior to CTPA. A protocol to request CTPAs is needed which is suited to the regional settings to avoid unnecessary CTPAs and its complications. Correspondence to: Al Alawi AM, Department of Medicine, Goulburn Valley Health, Australia, E-mail: dr.abdullahalalawi@gmail.com Received: March 03, 2018; Accepted: March 20, 2018; Published: March 24, 2018 Introduction Pulmonary embolism (PE) is a potentially fatal condition if left untreated. The annual crude incidence rate of PE in Australian was estimated to be 0.31 per 1000 in a community setting [1]. The 1-year case-fatality rate for PE is approximately 23% [2]. Efficient clinical evaluation and diagnostic testing is necessary to avoid delays in initiating therapy, which in turn reduces morbidity and mortality from PE [3]. Pulmonary angiography is the historical criterion standard for the diagnosis of PE, which has now been largely replaced by less invasive alternatives. CTPA is the investigation of choice for diagnosis of PE but requires the use of potentially nephrotoxic contrast agents and radiation [4,5]. Alternatively, as a result V/Q scans are commonly considered in patients with renal impairment, pregnant women and in young patients due to the lower dose of radiation [6]. Over the last decade, there has been a significant increase in CTPA use for diagnosis of PE [7]. Inappropriate CTPA use is associated with increases in health care expenditure and risks causing unnecessary harm for patient such as contrast-induced nephropathy and hypersensitivity reactions [8]. The positive rate of CTPA for PE can be as low as 7% but this rate can be increased to more than 30% with use of pre-test risk assessment tools [9-11]. Commonly applied stratifying tools are the Wells score and the revised Geneva score [12]. Depending on the risk factors for pulmonary embolism, patients are categorized into three groups: low (Geneva score 0–3, Wells score 0–1), intermediate (Geneva score 4–10, Wells score 2–6) or high (Geneva score ≥11, Wells score ≥7) [13]. The D-Dimer value is a very useful marker in low/intermediate probability groups and its use has been validated in several studies [12]. In the general population, the combination of D-Dimer testing and clinical assessment tools miss less than 2% of PEs [14]. Objectives of the study The objectives of this audit are: 1)To evaluate the appropriate use of CTPA (overuse/underuse) and the rate of positive results of CTPA for PE in a regional health setting. 2)To check the degree of adherence to an existing algorithm for using CTPA for PE. 3)To estimate the rate of contrast induced nephropathy. Al Alawi AM (2018) The patterns of ordering Computed Tomography Pulmonary Angiogram (CTPA) for diagnosis of pulmonary embolism (PE) in a rural health setting Volume 2(2): 2-3 Radiol Diagn Imaging, 2018 doi: 10.15761/RDI.1000127 Setting Goulburn Valley Health is a rural hospital located 200km northeast of Melbourne that provides care for a catchment population of approximately 120,000 people from the City of Greater Shepparton extending to southern New South Wales. The Medical imaging provides variety of services including CT scans and nuclear medicine.
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在农村卫生机构订购计算机断层扫描肺血管造影(CTPA)诊断肺栓塞(PE)的模式
背景:肺栓塞(PE)是一种危及生命的疾病,如果不及时治疗,总死亡率高达20%。对于肾功能正常的患者,CTPA是诊断PE的首选方法。几项研究表明,该测试被过度使用,而没有使用可用的预测工具,即Wells评分、修改日内瓦评分和D-Dimer方法:对2015年3月1日至2016年2月28日期间因疑似肺栓塞而进行CTPA的患者记录进行回顾性审查。通过人工查阅患者电子病历,获得患者的人口统计资料和不同评分系统的组成部分。结果:本研究期间共完成ctpa 249例。患者年龄中位数为63岁,女性占48.6%。34例(13.7%)患者被诊断为PE。只有196例(76.6%)患者进行了CXR作为初步调查。23例(14.0%)患者在CTPA后出现急性肾损伤。对所有接受CTP治疗的PE患者计算修订日内瓦评分,只有10例(4%)患者的修订日内瓦评分高概率(评分>11)。由于研究的回顾性性质,Wells的评分无法准确计算。结论:CTPA对肺栓塞的阳性诊断率为13.7%,低于英国皇家放射学院推荐的标准(15.4% ~ 37.4%)。此外,与澳大利亚一家医院进行的类似研究相比,这些发现被认为是低劣的。这些发现可能是由于风险评估工具(Geneva, Wells和D-Dimer)的使用不当以及在CTPA之前没有进行简单的胸部x线检查。为避免不必要的ctpa及其并发症,需要制定适合区域环境的ctpa请求协议。通讯:Al Alawi AM,医学部,Goulburn Valley Health, Australia, E-mail: dr.abdullahalalawi@gmail.com收稿日期:2018-03-03;录用日期:2018年3月20日;如果不及时治疗,肺栓塞(PE)是一种潜在的致命疾病。据估计,澳大利亚社区PE的年粗发病率为0.31 / 1000[1]。PE的1年病死率约为23%[2]。有效的临床评估和诊断测试是必要的,以避免延迟开始治疗,从而降低PE的发病率和死亡率[3]。肺血管造影是PE诊断的历史标准,现在已被侵入性较小的替代方法所取代。CTPA是诊断PE的首选检查,但需要使用潜在肾毒性造影剂和放疗[4,5]。另外,由于辐射剂量较低,肾损害患者、孕妇和年轻患者通常考虑进行V/Q扫描[6]。在过去十年中,CTPA在PE诊断中的应用显著增加[7]。不适当的CTPA使用会增加医疗保健支出,并有可能给患者造成不必要的伤害,如造影剂肾病和超敏反应[8]。CTPA对PE的阳性率可低至7%,但使用检测前风险评估工具可将该阳性率提高至30%以上[9-11]。常用的分层工具是Wells评分和修订后的Geneva评分[12]。根据肺栓塞的危险因素,将患者分为低(Geneva评分0-3分,Wells评分0-1分)、中(Geneva评分4-10分,Wells评分2-6分)和高(Geneva评分≥11分,Wells评分≥7分)三组[13]。d -二聚体值在低/中概率组中是一个非常有用的标记,其使用已在若干研究中得到验证[12]。在一般人群中,d -二聚体检测和临床评估工具相结合的pe漏报率不到2%[14]。本次审核的目的是:1)评估区域卫生机构CTPA对PE的适当使用(过度使用/使用不足)和CTPA阳性结果的比率。2)检查使用CTPA进行PE的现有算法的遵守程度。3)估计造影剂肾病的发生率。Al Alawi AM(2018)计算机断层扫描肺血管造影(CTPA)在农村卫生机构肺栓塞(PE)诊断中的应用模式vol . 2(2): 2-3 Radiol diagol Imaging, 2018 doi: 10.15761/RDI.1000127Goulburn Valley Health是一家乡村医院,位于墨尔本东北200公里处,为从大谢泼顿市延伸到新南威尔士州南部的集水区人口约12万人提供医疗服务。医学影像提供多种服务,包括CT扫描和核医学。
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