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Abstract：
OBJECTIVE: The aim of this study was to determine rates of and possible reasons for guideline-discordant ordering of CT pulmonary angiography for the evaluation of suspected pulmonary embolism (PE) in the emergency department.
METHODS: A retrospective review was performed of 212 consecutive encounters (January 6, 2016, to February 25, 2016) with 208 unique patients in the emergency department that resulted in CT pulmonary angiography orders. For each encounter, the revised Geneva score and two versions of the Wells criteria were calculated. Each encounter was then classified using a two-tiered risk stratification method (PE unlikely versus PE likely). Finally, the rate of and possible explanations for guideline-discordant ordering were assessed via in-depth chart review.
RESULTS: The frequency of guideline-discordant studies ranged from 53 (25%) to 79 (37%), depending on the scoring system used; 46 (22%) of which were guideline discordant under all three scoring systems. Of these, 18 (39%) had at least one patient-specific factor associated with increased risk for PE but not included in the risk stratification scores (eg, travel, thrombophilia).
CONCLUSIONS: Many of the guideline-discordant orders were placed for patients who presented with evidence-based risk factors for PE that are not included in the risk stratification scores. Therefore, guideline-discordant ordering may indicate that in the presence of these factors, the assessment of risk made by current scoring systems may not align with clinical suspicion.
METHODS: A retrospective review was performed of 212 consecutive encounters (January 6, 2016, to February 25, 2016) with 208 unique patients in the emergency department that resulted in CT pulmonary angiography orders. For each encounter, the revised Geneva score and two versions of the Wells criteria were calculated. Each encounter was then classified using a two-tiered risk stratification method (PE unlikely versus PE likely). Finally, the rate of and possible explanations for guideline-discordant ordering were assessed via in-depth chart review.
RESULTS: The frequency of guideline-discordant studies ranged from 53 (25%) to 79 (37%), depending on the scoring system used; 46 (22%) of which were guideline discordant under all three scoring systems. Of these, 18 (39%) had at least one patient-specific factor associated with increased risk for PE but not included in the risk stratification scores (eg, travel, thrombophilia).
CONCLUSIONS: Many of the guideline-discordant orders were placed for patients who presented with evidence-based risk factors for PE that are not included in the risk stratification scores. Therefore, guideline-discordant ordering may indicate that in the presence of these factors, the assessment of risk made by current scoring systems may not align with clinical suspicion.
摘要：
目的：本研究的目的是确定在急诊科评估可疑肺栓塞（PE）的CT肺动脉造影指南不一致排序的发生率和可能的原因。
方法：对急诊科的212例连续（2016年1月6日至2016年2月25日）的208例独特患者进行了回顾性研究，这些患者导致了CT肺动脉造影。对于每一次相遇，计算了修订后的日内瓦评分和两个版本的Wells标准.然后使用两级风险分层方法(PE不太可能与PE可能)对每次遭遇进行分类。最后,指南不一致排序的发生率和可能的解释通过深入图表审查进行评估.
结果：指南不一致研究的频率范围从53（25%）到79（37%），取决于所使用的评分系统;其中46(22%)在所有三种评分系统下都存在指南不一致.其中,18（39％）至少有一个患者特异性因素与PE风险增加相关，但未包括在风险分层评分中（例如，旅行,血栓形成倾向）。
结论：许多指南不一致的命令是针对那些存在基于证据的PE风险因素但未包括在风险分层评分中的患者。因此,指南不一致的排序可能表明，在存在这些因素的情况下，当前评分系统对风险的评估可能与临床怀疑不一致.
方法：对急诊科的212例连续（2016年1月6日至2016年2月25日）的208例独特患者进行了回顾性研究，这些患者导致了CT肺动脉造影。对于每一次相遇，计算了修订后的日内瓦评分和两个版本的Wells标准.然后使用两级风险分层方法(PE不太可能与PE可能)对每次遭遇进行分类。最后,指南不一致排序的发生率和可能的解释通过深入图表审查进行评估.
结果：指南不一致研究的频率范围从53（25%）到79（37%），取决于所使用的评分系统;其中46(22%)在所有三种评分系统下都存在指南不一致.其中,18（39％）至少有一个患者特异性因素与PE风险增加相关，但未包括在风险分层评分中（例如，旅行,血栓形成倾向）。
结论：许多指南不一致的命令是针对那些存在基于证据的PE风险因素但未包括在风险分层评分中的患者。因此,指南不一致的排序可能表明，在存在这些因素的情况下，当前评分系统对风险的评估可能与临床怀疑不一致.
