Improving Adherence to Pulmonary Embolism Evaluation Consensus Guidelines: A Multimodal Approach

Objective: Despite the publication of multiple widely accepted guidelines, Computed Tomography pulmonary angiography (CTPA) remains overutilized in the emergency (ED) setting for evaluating suspected pulmonary embolism (PE). We developed and evaluated a multimodal program that aimed to improve ordering provider adherence to CTPA use guidelines, and consequently positivity rate. Methods: We retrospectively identified all CTPA studies ordered for suspected PE over three years for each provider at a single-center ED, and reviewed radiology reports to determine PE positivity. We then implemented a program that included an education session, individualized performance feedback, and discussion of possible incentives to improve guideline adherence. We prospectively collected CTPA results for the following year. Our primary outcome was the difference in positivity rate between the final pre-intervention year and the post-intervention year. Our secondary outcome was individual provider positivity rate between the pre-intervention and post-intervention period. We compared the primary outcome using chi-squared testing, defining statistical significance as P<0.05. Results: We identified 4265 CTPA studies performed during the pre-intervention period, ordered by 25 providers. 1582 studies were ordered during the final year, with an 11.00% positivity rate (174/1582). In the post-intervention year, 1339 studies were ordered, with a significantly greater positivity rate of 13.67% (183/1339, P = 0.028). For our secondary outcome, mean provider positivity rate was 11.49% during the pre-intervention period, and increased to 14.24% in the post-intervention period. Discussion: We successfully implemented a multimodal program for ED providers that significantly increased the positivity rate of CTPAs ordered for suspected PE evaluation. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement The authors received no financial support for the research, authorship, and/or publication of this article. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: This study was approved by the institutional review board of Aultman Hospital. All patient-specific data was de-identified during analysis. Given the de-identified nature of the study, waiver of consent was obtained. I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes The authors declare that they had full access to all of the data in this study and the authors take complete responsibility for the integrity of the data and the accuracy of the data analysis. The clinical data used to support the findings of this study are restricted by the Baylor College of Medicine Institutional Review Board in order to protect patient privacy. Data are available from Eric M. Rohren (eric.rohren@bcm.edu) for researchers who meet the criteria for access to confidential data.