title: The impact of an electronic clinical decision support for pulmonary embolism imaging on the efficiency of computed tomography pulmonary angiography utilisation in a resource-limited setting.
abstract: BACKGROUND
  Pulmonary embolism (PE) is associated with high morbidity and mortality. Effective intervention requires prompt diagnosis. Computed tomography pulmonary angiography (CTPA) is sensitive and specific for PE and is the investigation of choice. Inappropriate CTPA utilisation results in unnecessary high radiation exposure and is costly. State-of-the-art electronic radiology workflow can provide clinical decision support (CDS) for specialised imaging requests, but there has been limited work on the clinical impact of CDS in PE, particularly in resource-constrained environments.
  
  
  OBJECTIVE
  To determine the impact of an electronic CDS for PE on the efficiency of CTPA utilisation in a resource-limited setting.
  
  
  METHODS
  In preparation, a PE diagnostic algorithm was distributed to hospital clinicians, explaining the combined role of the validated modified Wells score and the quantitative D-dimer test in defining the pre-test probability of PE. Thereafter, an automated, electronic CDS was introduced for all CTPA requests. Total CTPA referrals and the proportion positive for PE were assessed for three study phases: (i) pre- diagnostic algorithm; (ii) post-algorithm, pre-CDS; and (iii) post-CDS.
  
  
  RESULTS
  The proportion of CTPAs positive for PE after CDS implementation was almost double that prior to introduction of the diagnostic algorithm (phase 1 v. 3, 17.4% v. 30.7%; p=0.036), with a correspondingly significant decrease in the proportion of non-positive CTPAs (phases 1 v. 3, 82.6% v. 69.3%; p=0.015) During phases 2 and 3, no CTPAs were requested for patients with a modified Wells score of ≤4 and a documented negative D-dimer, indicating adherence to the algorithm.
  
  
  CONCLUSIONS
  Implementing an electronic CDS for PE significantly increased the efficiency of CTPA utilisation and significantly decreased the proportion of inappropriate scans.
authors.affiliation: Division of Radiodiagnosis, Department of Medical Imaging and Clinical Oncology, Faculty of Medicine and Health Sciences, Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa. cmurthy05@gmail.com.
authors.forename: C
authors.initials: C
authors.lastname: Murthy
authors.forename: R
authors.initials: R
authors.lastname: Davis
authors.forename: C F N
authors.initials: CF
authors.lastname: Koegelenberg
authors.forename: E M
authors.initials: EM
authors.lastname: Irusen
authors.forename: R D
authors.initials: RD
authors.lastname: Pitcher