CT scan pulmonary angiography is one of the go-to diagnostic tests in patients suspected of pulmonary embolism. However, most of the patients cautioned radiologists have started over-utilizing this exam.
Hawaiian researchers published a paper in the JACR stating that a novel, stern approach may be required to curb this long-standing overuse of the CTPA test. Typically, authors of the research suggested that patients should display their test results showing an abnormally higher level of the D-primer protein in blood to qualify for the CTPA test.
Hyo-Chun Yoon, MD and Ph.D., the corresponding author of the Department of Radiology of Hawaii Permanente Medical Group, along with colleagues also wrote, “Mandated use instead of recommending serum D-dimer test is needed to improve the use of CTPA to evaluate patients with a suspected case of acute PE.”
The issue may be divided into two parts, according to Yoon, colleagues – CTPA orders may be rising, specifically in American, and other corresponding positive rates are slowing down. A further Medicare analysis detected that CTPA usage for suspected cases of PE almost jumped fivefold in 2002 and 2009. However, there was a steady decline of positive rates to 5.9% from 7.3%.
In August 2021, the Hawaii Permanente started suggesting an increased threshold for D-dimer of 1.0 ug/mL fibrinogen-equivalent units to help patients qualify for the CTPA test. Patients were evaluated for potential acute PE in emergency departments during 2010 and 2019.
Yoon and colleagues also considered 6013 studies in total, comparing the PE rates in two years prior and post eight years of implementing the novel D-dimer guidance.
During this study period, more and more patients received CTPA exams without the D-dimer (approx 42.5%)than the ones with a 1.0 ug/mL threshold at 40.2%, according to reports from the group. Another 17.2% showed higher serum levels than recommended by the institution.
There was, however, a short-term increase in the rate of positivity immediately in years following the new recommendations of the medical group in 2013-14. Nonetheless, CTPA orders, as well as positivity rates, quickly fell to the levels observed before D-dimer updates.
Given the findings, Yoon along with co-authors hold that organizations should take a stern and stronger approach to curb this trend of over-imaging.
The authors explained, “The failure to regulate the usage of D-dimer serum with higher value of the threshold for patients undergoing CTPA test for suspected PE resulted in improper lasting compliance despite hopeful early and clear results. A stronger approach is necessary for all probability to get a positive long-term outcome.”
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