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Physician choices in pulmonary embolism testing
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 p...
Autores principales: | , , , , , , , , , , , |
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Formato: | Online Artículo Texto |
Lenguaje: | English |
Publicado: |
Joule Inc.
2021
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Materias: | |
Acceso en línea: | https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7773048/ https://www.ncbi.nlm.nih.gov/pubmed/33431544 http://dx.doi.org/10.1503/cmaj.201639 |
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author | Zarabi, Sahar Chan, Teresa M. Mercuri, Mathew Kearon, Clive Turcotte, Michelle Grusko, Emily Barbic, David Varner, Catherine Bridges, Eileen Houston, Reaves Eagles, Debra de Wit, Kerstin |
author_facet | Zarabi, Sahar Chan, Teresa M. Mercuri, Mathew Kearon, Clive Turcotte, Michelle Grusko, Emily Barbic, David Varner, Catherine Bridges, Eileen Houston, Reaves Eagles, Debra de Wit, Kerstin |
author_sort | Zarabi, Sahar |
collection | PubMed |
description | 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. |
format | Online Article Text |
id | pubmed-7773048 |
institution | National Center for Biotechnology Information |
language | English |
publishDate | 2021 |
publisher | Joule Inc. |
record_format | MEDLINE/PubMed |
spelling | pubmed-77730482021-01-11 Physician choices in pulmonary embolism testing Zarabi, Sahar Chan, Teresa M. Mercuri, Mathew Kearon, Clive Turcotte, Michelle Grusko, Emily Barbic, David Varner, Catherine Bridges, Eileen Houston, Reaves Eagles, Debra de Wit, Kerstin CMAJ Research 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. Joule Inc. 2021-01-11 /pmc/articles/PMC7773048/ /pubmed/33431544 http://dx.doi.org/10.1503/cmaj.201639 Text en © 2021 Joule Inc. or its licensors This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY-NC-ND 4.0) licence, which permits use, distribution and reproduction in any medium, provided that the original publication is properly cited, the use is noncommercial (i.e., research or educational use), and no modifications or adaptations are made. See: https://creativecommons.org/licenses/by-nc-nd/4.0/ |
spellingShingle | Research Zarabi, Sahar Chan, Teresa M. Mercuri, Mathew Kearon, Clive Turcotte, Michelle Grusko, Emily Barbic, David Varner, Catherine Bridges, Eileen Houston, Reaves Eagles, Debra de Wit, Kerstin Physician choices in pulmonary embolism testing |
title | Physician choices in pulmonary embolism testing |
title_full | Physician choices in pulmonary embolism testing |
title_fullStr | Physician choices in pulmonary embolism testing |
title_full_unstemmed | Physician choices in pulmonary embolism testing |
title_short | Physician choices in pulmonary embolism testing |
title_sort | physician choices in pulmonary embolism testing |
topic | Research |
url | https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7773048/ https://www.ncbi.nlm.nih.gov/pubmed/33431544 http://dx.doi.org/10.1503/cmaj.201639 |
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