title: Multicenter, randomized trial of quantitative pretest probability to reduce unnecessary medical radiation exposure in emergency department patients with chest pain and dyspnea.
abstract: BACKGROUND
  Use of pretest probability can reduce unnecessary testing. We hypothesize that quantitative pretest probability, linked to evidence-based management strategies, can reduce unnecessary radiation exposure and cost in low-risk patients with symptoms suggestive of acute coronary syndrome and pulmonary embolism.
  
  
  RESULTS
  This was a prospective, 4-center, randomized controlled trial of decision support effectiveness. Subjects were adults with chest pain and dyspnea, nondiagnostic ECGs, and no obvious diagnosis. The clinician provided data needed to compute pretest probabilities from a Web-based system. Clinicians randomized to the intervention group received the pretest probability estimates for both acute coronary syndrome and pulmonary embolism and suggested clinical actions designed to lower radiation exposure and cost. The control group received nothing. Patients were followed for 90 days. The primary outcome and sample size of 550 was predicated on a significant reduction in the proportion of healthy patients exposed to >5 mSv chest radiation. A total of 550 patients were randomized, and 541 had complete data. The proportion with >5 mSv to the chest and no significant cardiopulmonary diagnosis within 90 days was reduced from 33% to 25% (P=0.038). The intervention group had significantly lower median chest radiation exposure (0.06 versus 0.34 mSv; P=0.037, Mann-Whitney U test) and lower median costs ($934 versus $1275; P=0.018) for medical care. Adverse events occurred in 16% of controls and 11% in the intervention group (P=0.06).
  
  
  CONCLUSIONS
  Provision of pretest probability and prescriptive advice reduced radiation exposure and cost of care in low-risk ambulatory patients with symptoms of acute coronary syndrome and pulmonary embolism.
  
  
  BACKGROUND
  URL: http://www.clinicaltrials.gov. Unique identifier: NCT01059500.
authors.affiliation: Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis.
authors.forename: Jeffrey A
authors.initials: JA
authors.lastname: Kline
authors.forename: Alan E
authors.initials: AE
authors.lastname: Jones
authors.forename: Nathan I
authors.initials: NI
authors.lastname: Shapiro
authors.forename: Jackeline
authors.initials: J
authors.lastname: Hernandez
authors.forename: Melanie M
authors.initials: MM
authors.lastname: Hogg
authors.forename: Jennifer
authors.initials: J
authors.lastname: Troyer
authors.forename: R Darrel
authors.initials: RD
authors.lastname: Nelson
mesh_terms: D054058:Acute Coronary Syndrome / Q000150:complications / Q000000981:diagnostic imaging* / Q000191:economics / Q000628:therapy; D000328:Adult; D000787:Angina Pectoris / Q000000981:diagnostic imaging* / Q000191:economics / Q000209:etiology / Q000628:therapy; D001499:Bayes Theorem; D016507:Cardiology Service, Hospital / Q000191:economics; D017023:Coronary Angiography / Q000191:economics; D003362:Cost-Benefit Analysis; D003661:Decision Support Techniques; D003936:Diagnosis, Computer-Assisted; D003937:Diagnosis, Differential; D004417:Dyspnea / Q000000981:diagnostic imaging* / Q000191:economics / Q000209:etiology / Q000628:therapy; D004636:Emergency Service, Hospital / Q000191:economics; D005260:Female; D017721:Hospital Costs; D006801:Humans; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D018579:Patient Selection; D011237:Predictive Value of Tests; D011336:Probability; D011379:Prognosis; D011446:Prospective Studies; D011655:Pulmonary Embolism / Q000150:complications / Q000000981:diagnostic imaging* / Q000191:economics / Q000628:therapy; D011829:Radiation Dosage; D013997:Time Factors; D014057:Tomography, X-Ray Computed / Q000191:economics; D014481:United States; D019564:Unnecessary Procedures / Q000191:economics
keywords: acute coronary syndrome; decision making; diagnosis; malpractice; pulmonary embolism