Don’t image for suspected pulmonary embolism (PE) without moderate or high pre-test probability of PE
While deep vein thrombosis (DVT) and PE are relatively common clinically, they are rare in the absence of elevated blood d-Dimer levels and certain specific risk factors. Imaging, particularly computed tomography (CT) pulmonary angiography, is a rapid, accurate and widely available test, but has limited value in patients who are very unlikely, based on serum and clinical criteria, to have significant value. Imaging is helpful to confirm or exclude PE only for such patients, not for patients with low pre-test probability of PE.
These items are provided solely for informational purposes and are not intended as a substitute for consultation with a medical professional. Patients with any specific questions about the items on this list or their individual situation should consult their physician.
(1-5) The American College of Radiology (ACR) initially solicited expert opinion from physician leaders with its Board of Chancellors. A working group was then formed to further identify common clinical scenarios in which imaging may be misused and should be reconsidered. Members of the group included the physician chairs or vice chairs of seven ACR commissions such as Quality and Safety, Appropriateness Criteria and Metrics. An initial list of topics was narrowed down based on the highest potential for improvement, representing a broad range of tests and the availability of strong guidelines. Members then researched specific recommendations and evidentiary statements based on their expertise. Recommendations that were too general or were well covered by other existing measures and initiatives were eliminated to identify the final five things list.
(6-10) The Choosing Wisely initiative was presented to the organization’s physician leaders at a Board of Chancellors meeting and a working group selected five initial low-value imaging targets for reduced utilization. The second set of targets was created by the following working group, with the goals of minimizing unnecessary imaging and biopsy generated by discovery of incidental findings, improving patient safety through reduced radiation exposure, and reducing unnecessary consultations based on imaging findings.
- Pamela T. Johnson, MD, Chair, Choosing Wisely Recommendations
- Jacqueline A. Bello, MD, FACR, Chair of Commission on Quality and Safety
- Mythreyi B. Chatfield, PhD, Executive Vice President for Quality and Safety
- Jonathan Flug, MD, MBA, Quality Management Committee
- Jenny K. Hoang, MBBS, lead author on ACR White Paper for Managing Incidental Thyroid Nodules
- Alec J. Megibow, MD, MPH, FACR, Committee on Economics – Body Imaging Commission
- Pari V. Pandharipande, MD, MPH, Chair of Committee on Incidental Findings
- Saurabh Rohatgi, MD, Committee on Quality Experience – Commission on Patient and Family Centered Care
Research: For the topics related to incidental findings on imaging exams, the American College of Radiology has created evidence-based white papers to provide guidance to practicing radiologists on making management recommendations. The white paper publications and additional relevant literature serve as the evidence supporting those recommendations. For the remaining recommendations pertaining to body CT protocol design, published literature was reviewed to define acceptable indications for multiphase protocols.
ACR’s disclosure and conflict of interest policy can be found at www.acr.org.
Jacobo Kirsch, J, Brown, RKJ, Henry, TS, Javidan-Nejad, C, Jokerst, C, Julsrud, PR, Kanne, JP,Kramer, CM, Leipsic, JA, Panchal, KK, Ravenel, JG, Shah, AB, Mohammed, TLH, Woodard, PK, Abbara, S, Expert Panels on Cardiac and Thoracic Imaging. ACR Appropriateness Criteria® Acute Chest Pain- Suspected Pulmonary Embolism. [Online Publication]. Reston (VA) American College of Radiology (ACR); 2016. Available at: https://acsearch.acr.org/docs/69404/Narrative/
Torbicki A, Perrier A, Konstantinides S, et al. Guidelines on the diagnosis and management of acute pulmonary embolism: the Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC). Eur Heart J. 2008;29(18):2276-315.
Neff MJ. ACEP releases clinical policy on evaluation and management of pulmonary embolism. American Family Physician 2003;68(4):759–60.
Stein PD, Woodard PK, Weg JG, Wakefield TW, Tapson VF, Sostman HD, Sos TA, Quinn DA, Leeper KV, Hull RD, Hales CA, Gottschalk A, Goodman LR, Fowler SE, Buckley JD. Diagnostic pathways in acute pulmonary embolism: recommendations of the PIOPED II Investigators. Radiology 2007;242(1):15–21.