Appropriateness of PE workup at UCI based on Well’s CriteriaAmy Ni, MDCost Consciousness Project: March 2015

PE

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 positiveRadiology. 2010 Aug;256(2):625-32.

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?

Past Project

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

Lower extremity ultrasound performed in only 4 patients (18%); one had DVT and PE

20% had Well’s >4; 80% score <4, 50% score <2

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

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

Well’s score calculated and appropriateness of workup determined

Well’s Score

Results

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 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

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.

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

$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

Only 50% of cases were worked up appropriately

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

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