Category: Radiology

Overdiagnosis of Pulmonary Embolism

Another over-testing over-diagnosis article effectively illustrating issues endemic to our current medical culture.

They do a retrospective national database review regarding the impact of the introduction of CTPA protocol for rule-out PE, and note that we’ve diagnosed three times as many PEs in 2006 as we did in 1998.  And, by detecting more PEs, we managed to reduce mortality attributed to PE…along the same gradually decreasing trendline that was present prior to the introduction of CTPA.

Figure 2 is the truly damning graphic – look at all those extra PEs we’re finding and treating for effectively no substantial benefit.  Their secondary analysis was in-hospital anticoagulation complications on patients with any diagnosis of PE, which has jumped 71%.  Thank goodness we can put them on dagibatran now instead of coumadin and not be able to reverse their life-threatening bleeding episodes….

Again, we are testing people who shouldn’t be testing, finding disease of uncertain clinical significance, and harming them with overtreatment – and let’s not even start with the costs.

http://www.ncbi.nlm.nih.gov/pubmed/21555660

Liability Protections For Emergency Services

Smart folks at ACEP – tying liability reform to cost savings, which makes liability protection for Emergency Physicians an easier sell.  I have to say, the training environment these days is so skewed, I don’t think anyone graduating now knows how to practice without scanning everyone, as it’s become generally the standard of care.  The “quality of care” argument is a little new to me – but I certainly could move patients through more quickly, have less sign-out liability, etc., if I weren’t tying up beds waiting for scans.

But, the threat of a lawsuit is a big one.  And it’s not just us – so many PMDs refer their patients to the ED for a CT scan – whether the test is indicated, how miserable a malpractice hearing would it be to have testimony from the PMD who thought a CT was indicated after you declined to order it.

Next step beyond liability protection – Press-Ganey protection – for all these patients who expect answers, and CTs at the minimum, and aren’t going to fill out very favorable patient satisfaction surveys without getting what they want….

http://www.acep.org/Content.aspx?id=79958

The Cost-Effectiveness of Cardiac CTA

I was really hoping this would be a great article that convinced me that my hesitancy towards cardiac CTA is unfounded.  I feel, based on the literature, that we’re misusing cardiac CTA – or at least, the current generation of technology and reconstruction methods aren’t leading us in the right direction.  Angiography, whether radiographic or invasive, describes anatomy, and then we use the anatomy as our basis whether to attribute chest pain to cardiac causes or not.  Many situations, this works – the STEMI goes to the cath lab and the occlusion correlates with symptoms.  But, we’re trying to use CTA in our low-risk population to draw conclusions about the etiology of chest pain – and it’s much harder to say someone’s troponin-negative and EKG non-specific chest pain comes from a stenosis of a certain percentage.

The problem with their article is that they completely underestimate the number of false-positives cardiac CTA is generating.  There are several articles out there showing that the population considered for cardiac CTA is generally a population that just does great in follow-up, and that the number of negative follow-up studies generated after cardiac CTA – nuclear stress and invasive angiography – tend to far outnumber the number of positives.  They base their cost estimates on numbers that just don’t reflect reality, and I just can’t believe that cardiac CTA is a test that saves money and gives me better answers compared to functional cardiac testing.  If you wanted to use it as a screening tool for identifying a population that needs aggressive secondary-prevention of progressive atherosclerotic coronary disease, it would do great at that – but we know that plenty of ACS comes from ruptured plaque and hemodynamically insignificant disease, and someone who had a “negative” cardiac CTA that morning doesn’t preclude them from needing an enzymatic rule-out.

http://www.ncbi.nlm.nih.gov/pubmed/21427336