Of the interventions tested to reduce the overuse of CT pulmonary angiography for pulmonary embolism, clinical decision support may have an edge over educational or hospital-policy interventions, according to a recent systematic review.
Researchers reviewed 17 studies, 15 that evaluated interventions in the ED and two that were conducted on clinical wards. The studies tested four types of intervention: electronic clinical decision support (eight studies), educational interventions (seven studies), performance feedback reports (one study), and an institutional clinical pretest policy (one study). Results were published in the January Journal of Hospital Medicine.
Electronic clinical decision support was associated with a reduction in the use of imaging ranging between 8.3% and 25.4%. It was also associated with a rise in diagnostic yield of 3.4% to 4.4% and an increase in appropriate ordering of 18% to 19%. In one study that evaluated clinical decision support combined with performance and feedback reports, appropriate ordering increased by 8.8%.
Educational intervention strategies involved training sessions to bolster physician use of clinical decision rules to diagnose pulmonary embolism. Postintervention, three studies reported a significant impact on adherence to clinical guidelines, two found a significant decrease in imaging use, and one found an increase in diagnostic yield.
One study that assessed the impact of hospital policy found a significant reduction in CT pulmonary angiography use and a significant increase in diagnostic yield. However, only 4% of patient charts reported a clinical probability of pulmonary embolism.
Limitations of the review include that the studies were heterogeneous and often did not evaluate the safety of the interventions. In addition, only three studies were experimental in design with a comparative control group.
The growing use of electronic health records implies that clinical decision support tools will be implemented across the spectrum of diagnoses, including pulmonary embolism, an accompanying editorial noted. “Moving forward, [clinical decision support], perhaps coupled with performance feedback, seems to offer the best hope of reducing inappropriate CT [pulmonary angiography] use,” the editorialists wrote.