Suspected Pulmonary Embolism

Care Process Model APRIL 2021

Intermountain Imaging Criteria: Suspected Pulmonary Embolism

Through its Intermountain Imaging Criteria Project, Intermountain Healthcare has developed a suite of standardized care process models (CPMs) for the use of advanced imaging procedures in eight priority clinical areas. These evidence- WHAT’S INSIDE? based guidelines are intended to be widely implemented in order to improve patient safety, improve outcomes, and reduce unnecessary medical spending for the Medicare population and the U.S. health system overall. OVERVIEW: INTERMOUNTAIN IMAGING CRITERIA AUC CONTENT...... 2

Why Focus ON INTERMOUNTAIN IMAGING CRITERIA? SUSPECTED PULMONARY Advanced imaging procedures, including MRI, CT, PET, and nuclear medicine, facilitate rapid and accurate detection and / or EMBOLISM (PE) CARE PATHWAY diagnosis of disease. The volume of advanced imaging procedures prescribed to patients in the U.S. increased three- to four-fold from ALGORITHMS: 1996 – 2010 as the technologies became widely available.SMI The inflating costs of advanced imaging outstripped that of any other IGL, GAO NYDH Suspected acute pulmonary medical service. These inflating costs resulted in up to $20 – 30 billion in unnecessary advanced imaging spending each year. embolism in non-pregnant • High cost . Although the spending growth in advanced imaging dropped off after the early 2000s, 2014 costs to Medicare patients...... 5 Part B for advanced imaging exceeded $2.4 billion for common conditions alone.LEV, CMS1 Suspected acute pulmonary • Limited effectiveness . Multiple studies suggest that up to a third of advanced imaging procedures fail to contribute to embolism in pregnant patients. . . . 7 diagnosis or are clinically inappropriate.NYDH • Patient safety . Advanced diagnostic imaging often exposes the patient to ionizing radiation and / or contrast media, posing POINT-OF-ORDER CHECKLISTS. . . . . 9 additional medical risks that must be weighed against the potential benefits of the imaging procedure. RESOURCES...... 10 • Overdiagnosis and overtreatment . There is an risk of overdiagnosis and subsequent overtreatment that carries associated risks (e.g., drug reactions or unnecessary surgical interventions) if advanced imaging is performed in patients with low pretest BIBLIOGRAPHY...... 11 probability. The Intermountain Imaging Criteria approach seeks to avoid these risks. REFERENCES...... 13

GOALS AND MEASURES Indicates an Intermountain measure This CPM was developed by Intermountain clinical experts to outline appropriate use criteria (AUC) for advanced imaging for suspected pulmonary embolism (PE). These guidelines, together with those for other priority clinical areas, will improve the quality of care provided to patients by: • Increasing adherence to evidence-based AUC for the use of advanced imaging • Reducing imaging tests that do not conform to AUC or for which there are no guidelines • Decreasing system-wide spending on unnecessary advanced imaging services • Reducing risk associated with unwarranted patient exposure to radiation and / or contrast media • Documenting the incidence of a significant positive on advanced imaging tests and aligning with downstream care INTERMOUNTAIN IMAGING CRITERIA FOR Suspected Pulmonary Embolism (PE)

OVERVIEW: INTERMOUNTAIN IMAGING CRITERIA APPROPRIATE USE CRITERIA CONTENT Abbreviations used in this CPM Intermountain Imaging Criteria appropriate use criteria (AUC) support clinicians in providing evidence-based care to the patients they AUC = appropriate use criteria serve. Although appropriate use of Intermountain Imaging Criteria fulfills compliance requirements under PAMA, patients only fully CMS = Centers for Medicare and benefit from their use as they are deployed within the framework of a locally driven quality improvement program. To learn more about Medicaid Services Intermountain’s process for developing and maintaining AUC, visit: https://intermountainhealthcare.org/services/imaging-services/ intermountain-imaging-criteria/ . CPG = clinical practice guideline CPM = care process model The care process model approach CT = computed tomography Designed as Care Process Models (CPMs), the Intermountain Imaging Criteria AUC content is a blueprint that logically guides the CTPA = CT pulmonary angiogram delivery of evidence-based care via an algorithmic visual presentation (see pages 5 through 8). Although these Intermountain Imaging CUS = compression ultrasonography Criteria CPMs specifically focus on the appropriate use of advanced imaging, they can be viewed as portions of broader CPMs that guide not only diagnostic but therapeutic interventions for a specific disease or condition. CXR = chest x-ray (radiograph) Ideally, Intermountain Imaging Criteria CPMs are engaged early in the patient encounter and guide the various considerations that DVT = deep vein thrombosis lead to the ultimate decision regarding ordering of an imaging study. For providers who engage at the point of ordering, point-of- eGFR = estimated glomerular filtration rate order checklists are also included in the CPMs (beginning on page 9). These checklist-based guidelines are logically equivalent to the MRI = magnetic resonance imaging algorithms from which they are derived. PCP = primary care provider Knowing that local factors will invariably impact decisions about selecting the most appropriate exam, Intermountain Imaging Criteria PE = pulmonary embolism CPMs specify the generally preferred exam but also provide alternative choices that may be appropriate in certain clinical settings. PERC = pulmonary embolism rule-out criteria Relative imaging cost and radiation risk rankings PET = positron emission tomography RGS = revised Geneva score To further aid providers, each algorithm includes a ranking of relative costs and radiation risk for each advanced imaging test RVU = relative-value units recommended. The cost scale is derived using global non-facility relative-value units (RVUs) published by the Centers for Medicare and Medicaid Services (CMS) as a surrogate for cost.CMS2 The radiation risk is derived from data published in 2010 by the Health Physics V / Q = ventilation-perfusion Society. ACR, HPS VTE = venous thromboembolism Evidentiary review and ranking Intermountain used the following two conceptual frameworks for evidentiary review of relevant literature: 1 . The 2011 revision of the Oxford Centre for Evidence-Based Medicine (OCEBM) 2011 Levels of Evidence standard. This standard includes categorical levelling grades relevant to diagnostic studies and rates individual sources of evidence (published papers or other research data) on a five-point scale.OCE 2 .The extensively used Fryback and Thornbury conceptual framework, which uses six levels for assessing the efficacy of diagnostic imaging.FRY Each algorithmic presentation provides both rankings for the decision node (pairing of AUC and recommended / alternative tests). Using the algorithms and checklists Under “Care pathways” on page 3, there is an annotated algorithmic sample for a typical clinical scenario found in this CPM. Under “Point-of-Order Checklist” on page 4, there is an annotated sample of a typical point-of-order checklist for an imaging procedure recommended within the above sample algorithm.

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The Arabic number in the The Roman numeral in the orange box indicates Care pathways green box indicates an an evidence ranking derived from the Fryback & For each clinical scenario (e.g., suspected pulmonary embolism in non-pregnant patients), evidence ranking derived Thornbury scale FRY. For this scale, the higher the from the OCEBM scale OCE. number, the stronger the evidence ranking . there is an algorithmic presentation of the care pathway context for the imaging decisions For this scale, the lower made. This pathway contains not only the appropriate use criteria (AUC) and evidence- the number, the stronger Cost rankings are indicated based on a range the evidence ranking . developed from the CMS Global Relative Value based advanced imaging recommendations, but also what constitutes significant positive Units (RVUs) as follows:CMS2 imaging results and downstream care recommendations. Note the elements of this $ = 0 – 5 RVUs $$$ = 10 – 15 RVUs $$ = 5 – 10 RVUs presentation below and key information provided in each test recommendation box as $$$$ = 15+ RVUs shown at right. There is a legend at the bottom of each care pathway page. Radiation risk rankings use the scale developed by the American College of Radiology ACR. This Algorithms are grouped as indicated on page 2. rating framework offers the following six levels Imaging: primary recommendation for adult effective dose range risk: R3 = 1 – 10 mSv CTPA 1 VI $$ R4 R0 = 0 mSv R1 = < 1 mSv R4 = 10 – 30 mSv Imaging: alternative recommendation The decision node box encompasses recommended advanced imaging based on the R2 = 0 .1 – 1mSv R5 = 30 – 100 mSv presence of evidence-based appropriate use criteria (AUC) or expert consensus (where V / Q Scan 1 II $$ R3 evidence does not exist) . An alternative imaging recommendation has been included for when a test is contraindicated or otherwise clinically appropriate .

DECISION NODE #1 DO NOT treat . PE is excluded w / o imaging when EITHER PERC = 0 OR PERC > 0 AND RGS < 11 AND d-dimer < 500) This red flag signifies an urgent or emergency situation This symbol Suspected PE AUC met? (EITHER of the EMERGENCY REFERRAL CONSIDER further testing AND alternative diagnosis in non-pregnant 2 following conditions) if patient unstable (sometimes this red flag indicates a scenario that may indicates a require bypassing the AUC logic) . patients • PE highly likely (PERC > 0 AND no common clinical RGS ≥ 11) Significant scenario . Imaging: primary § OR yes positive result? recommendation • PE possible (PERC > 0 AND PE present This symbol indicates an Intermountain internal measure . CTPA $$ R4 TREAT for PE per 1 VI yes RGS 0 – 10 AND d-dimer positive* system-wide Intermountain measures incidence of significant positive [≥ 500, or age x 10 if 50+ years]) Imaging: alternative recommendation† Significant protocol results on advanced imaging tests . ¶ V / Q positive result? 1 II $$ R3 Scan High probability for PE no no DO NOT TREAT DO NOT treat . PE is excluded w / o CONSIDER alternative imaging when EITHER diagnosis Downstream care recommendations are general PERC = 0 OR PERC > 0 AND RGS < 11 AND d-dimer < 500) guidelines and are subject to the discretion of individual CONSIDER further testing AND healthcare providers and the providers’ system protocols . alternative diagnosis

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Point-of-order checklists See abbreviations on page 2 . For each advanced imaging test (e.g., CTPA and V / Q scan), there is a checklist that compiles all of the appropriate use criteria from each clinical scenario (shown in the care pathways) for that test. These are presented in a checklist format for the provider to select the appropriate scenario AND the criteria that apply to the patient’s situation.

TABLE 1 . CTPA appropriate use indications (PRIMARY recommendation)

Suspected PE in NON-PREGNANT patients (IF EITHER of these 2 situations): PE highly likely (PERC > 0 AND RGS ≥ 11) OR PE possible (PERC > 0 AND RGS 0 – 1 AND d-dimer positive [≥ 500, or age x10 if ≥ 50 years])

Tables included on page 9 indicate when (ALTERNATIVE recommendation) the test is a primary recommendation Suspected PE in PREGNANT patients (ALL criteria must be or an alternate recommendation. met for either of the following 2 sets of conditions): Abnormal CXR No DVT symptoms No contrast allergy AND eGFR ≥ 30 OR Non-diagnostic V / Q Scan No contrast allergy AND eGFR ≥ 30

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SUSPECTED PULMONARY EMBOLISM (PE) CARE PATHWAY ALGORITHMS See abbreviations on page 2 .

DECISION NODE #1 DO NOT TREAT . (PE is excluded w / o imaging when EITHER Suspected PE PERC = 0 OR PERC > 0 AND RGS < 11 AND d-dimer < 500) in non-pregnant AUC met? (EITHER of the EMERGENCY REFERRAL CONSIDER further testing AND alternative diagnosis patients 2 following conditions) if patient is unstable no • PE highly likely (PERC > 0 AND RGS ≥ 11) * A negative or positive result Imaging: primary Significant OR yes § of a qualitative d-dimer test recommendation positive result? should be used in the same • PE possible (PERC > 0 AND way as an age-adjusted PE present RGS 0 – 10 AND d-dimer positive* TREAT for PE per quantitative d-dimer. Age- CTPA 1 VI $$ R4 yes adjustment of qualitative [≥ 500, or age x 10 if ≥ 50 years]) system-wide d-dimers is not possible. If Imaging: alternative protocol d-dimer failed to result or is † Significant likely to be unreliable due to recommendation ¶ comoribities, imaging should positive result? be performed. V / Q Scan 1 II $$ R3 High probability for PE † Use imaging alternative if contrast allergy OR no eGFR < 30. ‡ Additional testing or no consultation may be pursued if persistent concern for PE, DO NOT TREAT particularly in patients with high pretest probability. DO NOT TREAT . (PE is excluded w / o CONSIDER further § If CTPA non-diagnostic, imaging when EITHER testing AND alternative PERFORM V / Q Scan OR diagnosis PERFORM bilateral CUS, PERC = 0 OR PERC > 0 AND and TREAT if DVT present. RGS < 11 AND d-dimer < 500) If CUS negative, CONSIDER additional testing or CONSIDER further testing AND thrombosis consult. ¶ If V / Q Scan indeterminate alternative diagnosis or non-diagnostic, PERFORM CTPA if not contraindicated. If CTPA contraindicated, PERFORM bilateral CUS and TREAT if DVT present. If CUS negative, CONSIDER additional testing or thrombosis consult.

LEGEND

Urgent or Emergency OCEBM Fryback & Thornbury Intermountain R0 (0 mSv) R 3 (1 – 10 mSv) R 4 (10 – 30 mSv) See page 2 – 3 for explanation. Clinical 2 II Scenario Situation Level of Evidence Level of Evidence Measure $ (0 – 5 RVUs) $ $ (5 – 10 RVUs) $ $ $ (10 – 15 RVUs) $ $ $ $ (15+ RVUs)

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DECISION NODE #1 KEY EVIDENCE Fesmire FM, Brown MD, Espinosa JA, et al. Critical issues in the evaluation and Raja AS, Greenberg JO, Qaseem A, Denberg TD, Fitterman N, Schuur JD; Clinical Guidelines management of adult patients presenting to the emergency department with Committee of the American College of Physicians. Evaluation of patients with suspected pulmonary embolism. Ann Emerg Med. 2011;57(6):628-652. suspected acute pulmonary embolism: Best practice advice from the Clinical Guidelines Committee of the American College of Physicians. Ann Intern Med. Kabrhel C, Courtney DM, Camargo CA, et al. Factors associated with positive D-dimer 2015;163(9):701-711. results in patients evaluated for pulmonary embolism. Acad Emerg Med. 2010;17(6):589-597. van Belle A, Büller HR, Huisman MV, et al; Christopher Study Investigators. Effectiveness of managing suspected pulmonary embolism using an algorithm combining clinical Konstantinides SV, Meyer g, Becattini C, et al. 2019 ESC Guidelines for the diagnosis and probability, D-dimer testing, and computed tomography. JAMA. 2006;295(2):172-179 management of acute pulmonary embolism developed in collaboration with the European Society (ERS). Eur Heart J. 2020;41(4):543-603. Lim W, Le Gal G, Bates SM, et al. American Society of Hematology 2018 guidelines for management of venous thromboembolism: Diagnosis of venous thromboembolism. Blood Adv. 2018;2(22):3226-3256. (For a list of references for all decision nodes, see the complete bibliography on pages 11 through 13)

LEGEND

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DECISION NODE #2A REFER to obstetrics See abbreviations on page 2 . CONSIDER alternative Suspected PE AUC met? (IF ALL) EMERGENCY REFERRAL if patient unstable diagnosis in pregnant • Normal CXR • No DVT symptoms patients (-) • No contrast allergy yes Imaging: primary recommendation TREAT for PE per • eGFR ≥ 30 V / Q Scan* 2 V $$ R3 Result? (+) Venous Thromboembolism CPM (non-diagnostic) or other system- no wide protocol * V / Q scan results can be reported in different formats. This CPM is based on the 3-category system: (1) Normal (negative), (2) High-probability (positive), and (3) DECISION NODE #2B Non-diagnostic. REFER to obstetrics If results are in an alternate format AUC met? (IF ALL) CONSIDER alternative EMERGENCY REFERRAL diagnosis which uses additional • Abnormal CXR if patient unstable probability descriptions, • No DVT symptoms Low Probability, • No contrast allergy AND Intermediate (-) Probability, and Very eGFR ≥ 30 Imaging: alternative recommendation Low Probability OR (IF ALL) † should be considered yes CTPA 2 VI $$ R4 Result? (+) Non-diagnostic, • Non-diagnostic V / Q Scan Non-diagnostic, and • No contrast allergy AND (non-diagnostic) Normal / Negative, eGFR ≥ 30 respectively. † If CTPA PERFORM bilateral CUS. contraindicated, no TREAT if DVT present. If PERFORM bilateral CUS. TREAT if DVT CUS negative, CONSIDER detected. If CUS PERFORM bilateral CUS. further testing or negative, CONSIDER TREAT if DVT present. If CUS negative, CONSIDER thrombosis consult. further testing or further testing, risk / benefit of anticoagulation, and thrombosis consult. referral to obstetrics and / or thrombosis consult.

LEGEND

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DECISION NODE #2A & #2B KEY EVIDENCE Leung AN, Bull TM, Jaeschke R, et al; ATS/STR Committee on Pulmonary Embolism in Ridge CA, McDermott S, Freyne BJ, Brennan DJ, Collins CD, Skehan SJ. Pulmonary Pregnancy. An official American Thoracic Society/Society of Thoracic Radiology embolism in pregnancy: Comparison of pulmonary CT angiography and lung clinical practice guideline: Evaluation of suspected pulmonary embolism in scintigraphy. AJR Am J Roentgenol. 2009;193(5):1223-1227. pregnancy. Am J Respir Crit Care Med. 2011;184(10):1200-1208. van der Pol LM, Tromeur C, Bistervels IM, et al. Pregnancy-Adapted YEARS Algorithm for Lim W, Le Gal G, Bates SM, et al. American Society of Hematology 2018 guidelines for diagnosis of suspected pulmonary embolism. N Engl J Med. 2019;380(12):1139-1149. management of venous thromboembolism: Diagnosis of venous thromboembolism. Righini M, Robert-Ebadi H, Elias A, et al. Diagnosis of pulmonary embolism during Blood Adv. 2018;2(22):3226-3256. pregnancy: A multicenter prospective management outcome study. Ann Intern Med. Revel MP, Cohen S, Sanchez O, et al. Pulmonary embolism during pregnancy: Diagnosis 2018 Dec 4;169(11):766-773. with lung scintigraphy or CT angiography? Radiology. 2011;258(2):590-598 (For a list of references for all decision nodes, see the complete bibliography on pages 11 through 13)

LEGEND

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POINT-OF-ORDER CHECKLISTS See abbreviations on page 2 .

The provider must check BOTH: TABLE 1 . CTPA appropriate use indications TABLE 2 . V / Q Scan appropriate use indications 1. The box next to the relevant clinical scenario (PRIMARY recommendation) (PRIMARY recommendation) 2. EACH AUC box that applies to the patient’s situation Suspected PE in NON-PREGNANT patients (IF EITHER of Suspected PE in PREGNANT patients (IF ALL): these 2 situations): Normal CXR PE highly likely (PERC > 0 AND RGS ≥ 11) No DVT symptoms OR No contrast allergy PE possible (PERC > 0 AND RGS 0 – 10 eGFR ≥ 30 AND d-dimer positive [≥ 500, or age x10 if ≥ 50 years]) (ALTERNATIVE recommendation) (ALTERNATIVE recommendation) Suspected PE in NON-PREGNANT patients (IF EITHER of Suspected PE in PREGNANT patients (ALL criteria must be these 2 situations): met for either of the following 2 sets of conditions): PE highly likely (PERC > 0 AND RGS ≥ 11) Abnormal CXR OR No DVT symptoms PE possible (PERC > 0 AND RGS 0 – 10 No contrast allergy AND eGFR ≥ 30 AND d-dimer positive [≥ 500, or age x10 if ≥ 50 years]) OR Non-diagnostic V / Q Scan No contrast allergy AND eGFR ≥ 30

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RESOURCES FACT SHEET FOR PATIENTS AND FAMILIES Fact sheets: Computed Tomography (CT) Scan

What is a CT Scan? A CT scan (sometimes called a CAT scan) is a test that uses x-rays to create clear, detailed images of body tissues. CT scans help doctors diagnose and treat • Computed Tomography (CT) Scan Intermountain provides educational materials designed to support many types of injuries and illnesses. A CT scan can be performed on any part of the body. How does a CT scan work? During a CT scan, special x-ray equipment takes many images from different angles by rotating an FACT SHEET FOR PATIENTS AND FAMILIES x-ray tube around the body. A computer then uses the information to create detailed images. The images (English) / (Spanish) providers in their efforts to care for, educate, and engage patients A CT scan uses x-rays to create detailed look like thin cross-sections (“slices”) of the area images of body tissues. CT scans are being studied. generally painless, fast, and easy. Some CT scans use a clear liquid Radiationcalled contrast Exposure in Medical Tests (a special dye that shows up on x-rays). During the • Tell your doctor about all of the medicines CT scan, the contrast helps to highlight blood vessels you take. Include all herbs, vitamins, over-the- or certain types of tissue. What is radiation? counter drugs (like allergy pills or aspirin), inhalers, and their families. Radiation is a form of energy usedor patches. in common What do I need to do next? How long will it take? medical tests. Radiation can pass– throughYou may body be prescribed medication to take a few • Radiation Exposure in Medical Tests Most CT scans usually take 15 minutes or less. If tissues and show up on a camera todays create before detailed your procedure. 1 If you are pregnant or might be your CT includes contrast, the testimages may beof what'slonger, happening in the body. The images – Follow your doctor’s instructions aboutpregnant, your tell your doctor. Some depending on the type of contrasthelp used. your Your doctor doctor diagnose or treat a problem. procedures that use radiation are not medicines, especially if you are taking metformin or the CT technician can tell you how much time appropriate in pregnancy, unless the Common imaging procedures that(Glucophage). use radiation Youare: may need to stop taking it your test will take. medical need is severe. • X-rays before your procedure and monitor your blood 2 Keep a history of all your procedures • Mammograms glucose more closely in the days after. How should I prepare? involving radiation, and share this • Bone density scans Intermountain’s patient education materials You’ll meet with your doctor to learn about the test • If directed, avoid food and drink beforeinformation the with your doctor. (English) / (Spanish) FACT SHEET FOR PATIENTS AND FAMILIES complement and and how to prepare. Here are some• CTtips: scans test. If contrast will be used in your CTFind scan, a printable imaging record at • Angiograms do not eat or drink anything for 2 hoursradiologyinfo.org/en/safety before /. • Tell your doctor about your allergies. Your the scan. 3 Talk to your doctor about what imaging doctor especially needs to know• ifNuclear you have medicine asthma exams is best for your condition and why. or are allergic to any foods or medications.(Note: MRI Ifand you’ve ultrasound tests• Wear do not loose, use radiation comfortable clothing. You may be had a bad reaction to contrast inthat the puts past, you you at mayrisk.) askedDeep to put on a Veingown. Thrombosis (DVT) and Embolism need to take medication the day before the scan. • Tell your doctor and the CT technician if you reinforce clinical team interventions by providing a means for Is there a risk from radiation?are pregnant or you may be Ampregnant. I more at risk as I get older? We’re all exposed to radiation 24 hoursWhat a day is from it? The cancer risk from an imaging test is lower the many different sources like the sun,Deep the ground,vein thrombosis the air, [throm-BOH-sis]older a person — also gets, called and DVT1 the — highest is risk is for and even food. a blood clot (or thrombus) inchildren. veins in theDoctors deep tissuestake special of the care in choosing • Deep Vein Thrombosis and Embolism Medical tests use very small amountsbody. of Most radiation. DVTs are found inimaging the veins tests of for the children, leg. and facilities adjust the radiation to fit each individual child. For more For example, a chest x-ray exposesDVTs you areto about dangerous the . They can damage the valves in your same amount of radiation as living in your natural information on radiation for children, see the veins, leading to chronic pain and swelling. They can also patients to reflect and learn in another mode and at their own pace. surroundings for about 10 days. Image Gently site at imagegently.org. break loose and travel in your veins. There is always risk of cancer when people are A blood clot that has broken loose is called an embolism exposed to radiation. With medical tests, the risks of radiation exposure are often very low[EM-BUH-liz-uhm] compared to. If it has traveled to the Wise lungs, Choices it’s called a pulmonary embolism (PE). A PE can be life-threatening. Normal Deep vein Embolus the benefits, such as finding cancer or another disease blood flow thrombrosis (English) / (Spanish) in its early stages. Discuss planned imaging procedures and alternatives with your doctor. Be sure to ask For most medical tests, the added cancerWhat risk is areso the symptoms?any questions you may have, such as: small that it can’t be measured on an individual basis. What causes it? The symptoms of DVT can •vary What depending will this onprocedure the tell you? Whether or not we have any medical tests, 42 out of individual person and the site• How of the will clot. what The you most learn improve my care?Blood clots can be caused by anything that slows Intermountain’s Care Process Models (CPMs) 100 people will develop cancer in their lifetime. outline evidence-based common symptoms are: • What’s the risk of NOT having thisor procedure? stops blood circulation. This can include: • Pain or swelling in the affected area (such as a leg) • Sitting for a long time (especially 4 hours or more) Redness or warmth in the affected area • • Long periods of bed rest, as when hospitalized 1 Sometimes the first or paralyzed noticeable symptoms • Injury to a deep vein from surgery, a are from a PE. These Possible broken bone, or other trauma site of symptoms include: thrombosis guidelines for patient care. In addition to the suite of Intermountain • Shortness of breath • Pregnancy and the first 6 weeks after giving that comes on birth (due to hormonal changes, less physical suddenly activity, and the uterus pressing on blood vessels) • Chest pain that • Surgery (especially joint replacement, gets worse when gynecological surgery, or a C-section) Normal you breathe deeply outline or cough • Birth control pills or hormone therapy of leg • Coughing or • Cancer and some of its treatments Imaging Criteria CPMs, Intermountain provides topical CPMs that vomiting blood Leg is • Heart failure swollen If you experience below the • Intravenous (IV) catheter in a large vein obstruction symptoms of PE, call 911 and get medical • Being overweight or obese help immediately • Smoking have been developed by expert clinical teams. They can be accessed • Personal or family history of DVT or embolism 1 by navigating to intermountainphysician org. and selecting Care Process Models in the Tools and Resources drop-down menu. To access Intermountain’s Imaging Criteria CPMs and supporting materials, visit: https://intermountainhealthcare.org/services/imaging- services/intermountain-imaging-criteria/ .

Related Care Process Models (CPMs):

Care Process Model JUNE 2012

A PHYSICIAN’S GUIDE TO Imaging Radiation Exposure

This care process model (CPM) was developed by Intermountain Healthcare’s Cardiovascular Clinical Program and Imaging Clinical Service. It provides basic information on radiation used in imaging and recommends specific factors to consider when choosing an imaging strategy. It also describes steps Intermountain is taking to begin collecting each patient’s cumulative radiation exposure from selected tests. This CPM was created as part of a multi-year (2011-2012) board goal; future documents will elaborate on this information and provide more detailed guidance. Please note that while this document presents an evidence-based approach that is appropriate for most patients, it should be adapted to meet the needs of individual patients and situations,and should not replace clinical judgment.

ON Key points Why Focus IMAGING RADIATION? • Imaging procedures that use ionizing radiation may pose a small increase in a patient’s lifetime cancer risk. Imaging procedures that use radiation are • Imaging radiation can pose a small increase in a patient’s lifetime essential tools for medical diagnosis and treatment, and no published studies have cancer risk. See the first key point at left. conclusively linked cancer with radiation at the levels used in imaging. However, 1 • The use of imaging tests that rely on consensus statements from the American College of Radiology and other clinical radiation — particularly CT scans — organizations suggest that it is reasonable to act on the assumption that low-level has grown dramatically. Annual imaging radiation may have a small risk of causing cancer. The general risk from the radiation exposure in the US increased radiation in various imaging tests has been estimated, but the risk also depends twenty-fold between 1980 and 20051; up to on the patient’s age, body size, and sex. For more details, see page 2. 72 million CT scans are performed annually in the US (based on 2006 and 2007 data).3 • Imaging tests and procedures vary in radiation exposure. For example, when • The media has focused recently on compared to a chest radiograph, a chest CT scan exposes a patient to approximately the increase in imaging radiation 70 times more radiation and a CT angiogram exposes the patient to approximately and its risks. Recent examples include 2 coverage in USA Today, Time, Newsweek, 160 times more radiation. See page 2 for a comparison of common procedures. the New York Times, and on MSNBC. This • The benefits of an indicated imaging procedure far outweigh the risks. However, may prompt questions from your patients. healthcare providers should work together to decrease radiation exposure by: • Intermountain Healthcare has set a goal to monitor imaging radiation – Ensuring that an ordered procedure is necessary and appropriate. The exposure and educate providers referring physician and radiologist play key roles in this process. See page 3 for and patients about it. This CPM guidance on evaluating whether to order an imaging test that uses radiation, describes the efforts currently underway. with example situations when alternative imaging strategies may be preferable. – Not repeating tests unnecessarily. Checking the record for previous results Goals OF THIS CPM (and asking the patient about results from other facilities) is an important, • Inform referring providers about ionizing radiation, relative estimated exposures and commonsense measure. risks, and how age and sex affect risk. – Using radiation exposures that are as low as reasonably achievable for the • Provide brief guidance on factors that can images required. See page 3 for information on how Intermountain’s Imaging inform the decision to order an imaging test. Service works to ensure radiation safety, including the use of ALARA (as low • Help referring providers discuss imaging as reasonably achievable) dosing while ensuring quality images. radiation with patients. • Introduce Intermountain’s efforts to • It’s important to communicate with patients and families about the benefits measure imaging radiation exposures. and potential risks of a proposed procedure. Patients may have questions (even if unstated) about imaging radiation, based on media coverage of this topic. For an indicated procedure, a clear and informative conversation can help patients understand the small risk and place it in context with the benefits of the procedure. See page 4 for guidance on talking with patients and links to patient education resources that can help in the conversation.

Diagnosis and Imaging Radiation Management of Venous Exposure CPM Thromboembolism CPM

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BIBLIOGRAPHY

NODE #1 14. Mos ICM, Klok FA, Kroft LJM, de Roos A, Dekkers OM, Huisman MV. Safety of ruling out acute 1. Crawford F, Andras A, Welch K, Sheares K, Keeling D, Chappell FM. D-dimer test for excluding the pulmonary embolism by normal computed tomography pulmonary angiography in patients with diagnosis of pulmonary embolism. Cochrane Database Syst Rev. 2016;(8):CD010864. an indication for computed tomography: systematic review and meta-analysis. J Thromb Haemost. 2009;7(9):1491-1498. 2. Cueto SM, Cavanaugh SH, Benenson RS, Redclift MS. Computed tomography scan versus ventilation- perfusion lung scan in the detection of pulmonary embolism. J Emerg Med. 2001;21(2):155-164. 15. Phillips JJ, Straiton J, Staff RT. Planar and SPECT ventilation / perfusion imaging and computed tomography for the diagnosis of pulmonary embolism: a systematic review and meta-analysis of the 3. Fabiá Valls MJ, van der Hulle T, den Exter PL, Mos IC, Huisman MV, Klok FA. Performance of a literature, and cost and dose comparison. Eur J Radiol. 2015;84(7):1392-1400. diagnostic algorithm based on a prediction rule, D-dimer and CT-scan for pulmonary embolism in patients with previous venous thromboembolism. A systematic review and meta-analysis. J Thromb 16. Raja AS, Greenberg JO, Qaseem A, Denberg TD, Fitterman N, Schuur JD; Clinical Guidelines Haemost. 2015;113(2):406-413. Committee of the American College of Physicians. Evaluation of patients with suspected acute pulmonary embolism: best practice advice from the Clinical Guidelines Committee of the American 4. Fesmire FM, Brown MD, Espinosa JA, et al. Critical issues in the evaluation and management of adult College of Physicians. Ann Intern Med. 2015;163(9):701-711. patients presenting to the emergency department with suspected pulmonary embolism. Ann Emerg Med. 2011;57(6):628-652. 17. Safriel Y, Zinn H. CT pulmonary angiography in the detection of pulmonary emboli: a meta-analysis of sensitivities and specificities. Clin Imaging. 2002;26(2):101-105. 5. Garg K, Welsh CH, Feyerabend AJ, et al. Pulmonary embolism: diagnosis with spiral CT and ventilation-perfusion scanning — correlation with pulmonary angiographic results or clinical 18. Stein PD, Hull RD, Patel KC, et al. D-dimer for the exclusion of acute venous thrombosis and outcome. Radiology. 1998;208(1):201-208. pulmonary embolism: a systematic review. Ann Intern Med. 2004;140(8):589-602. 6. Hayashino Y, Goto M, Noguchi Y, Fukui T. Ventilation-perfusion scanning and helical CT in suspected 19. van Belle A, Büller HR, Huisman MV, et al; Christopher Study Investigators. Effectiveness of managing pulmonary embolism: Meta-analysis of diagnostic performance. Radiology. 2005;234(3):740-748. suspected pulmonary embolism using an algorithm combining clinical probability, D-dimer testing, and computed tomography. JAMA. 2006;295(2):172-179. 7. Kan Y, Yuan L, Meeks JK, Li C, Liu W, Yang J. The accuracy of V / Q SPECT in the diagnosis of pulmonary embolism: A meta-analysis. Acta Radiol. 2015;56(5):565-572. NODES #2A & #2B 8. Kabrhel C, Courtney DM, Camargo CA, et al. Factors Associated With Positive D-dimer Results in 1. Andreou AK, Curtin JJ, Wilde S, Clark A. Does pregnancy affect vascular enhancement in patients Patients Evaluated for Pulmonary Embolism. Acad Emerg Med. 2010;17(6):589-597. undergoing CT pulmonary angiography? Eur Radiol. 2008;18(12):2716-2722. 9. Konstantinides SV, Meyer g, Becattini C, et al. 2019 ESC Guidelines for the diagnosis and 2. Astani SA, Davis LC, Harkness BA, Supanich MP, Dalal I. Detection of pulmonary embolism during management of acute pulmonary embolism developed in collaboration with the European Society pregnancy: comparing radiation doses of CTPA and pulmonary scintigraphy. Nucl Med Commun. (ERS). Eur Heart J. 2020;41(4):543-603. 2014;35(7):704-711. 10. Li J, Feng L, Li J, Tang J. Diagnostic accuracy of magnetic resonance angiography for acute pulmonary 3. Balan KK, Critchley M, Vedavathy KK, Smith ML, Vinjamuri S. The value of ventilation-perfusion embolism — a systematic review and meta-analysis. Vasa. 2016;45(2):149-154. imaging in pregnancy. Br J Radiol. 1997;70(832):338-340. 11. Lim W, Le Gal G, Bates SM, et al. American Society of Hematology 2018 guidelines for management 4. Bates SM, Jaeschke R, Stevens SM, et al. Diagnosis of DVT. Chest. 2012;141(2):e351S-e418S. of venous thromboembolism: Diagnosis of venous thromboembolism. Blood Adv. 2018;2(22):3226- 5. Cahill AG, Stout MJ, Macones GA, Bhalla S. Diagnosing pulmonary embolism in pregnancy using 3256. computed-tomographic angiography or ventilation-perfusion. Obstet Gynecol. 2009;114(1):124-129. 12. Lucassen W, Geersing G-J, Erkens PMG, et al. Clinical decision rules for excluding pulmonary 6. Centers for Disease Control and Prevention (CDC). Pregnancy-related mortality surveillance-United embolism: a meta-analysis. Ann Intern Med. 2011;155(7):448-460. States, 1991-1999. MMWR Morb Mortal Wkly Rp. 2003;52(SS02);1-8. 13. Moores LK, Jackson WL Jr, Shorr AF, Jackson JL. Meta-analysis: Outcomes in patients with suspected 7. Chan WS, Lee A, Spencer FA, et al. Predicting deep venous thrombosis in pregnancy: out in "Left" pulmonary embolism managed with computed tomographic pulmonary angiography. Ann Intern field? Ann Intern Med. 2009;151(2):85-92. Med. 2004;141(11):866-874.

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BIBLIOGRAPHY, CONTINUED

8. Chan WS, Ray JG, Murray S, Coady GE, Coates G, Ginsberg JS. Suspected pulmonary embolism in 23. Nijkeuter M, Ginsberg JS, Huisman MV. Diagnosis of deep vein thrombosis and pulmonary embolism pregnancy: clinical presentation, results of lung scanning, and subsequent maternal and pediatric in pregnancy: a systematic review. J Thromb Haemost. 2006;4(3):496-500. outcomes. Arch Intern Med. 2002;162(10):1170-1175. 24. O’Neill J, Murchison JT, Wright L, Williams J. Effect of the introduction of helical CT on radiation dose 9. Chan WS, Spencer FA, Ginsberg JS. Anatomic distribution of deep vein thrombosis in pregnancy. in the investigation of pulmonary embolism. Br J Radiol. 2005;78(925):46-50. CMAJ. 2010;182(7):657-660. 25. Parker MS, Hui FK, Camacho MA, Chung JK, Broga DW, Sethi NN. Female breast radiation exposure 10. Daftary A, Gregory M, Daftary A, Seibyl JP, Saluja S. Chest radiograph as a triage tool in the imaging- during CT pulmonary angiography. AJR Am J Roentgenol. 2005;185(5):1228-1233. based diagnosis of pulmonary embolism. AJR Am J Roentgenol. 2005;185(1):132-134. 26. Perisinakis K, Seimenis I, Tzedakis A, Damilakis J. Perfusion scintigraphy versus 256-slice CT 11. Doshi SK, Negus IS , Oduko JM. Fetal radiation dose from CT pulmonary angiography in late angiography in pregnant patients suspected of pulmonary embolism: comparison of radiation risks. pregnancy: a phantom study. Br J Radiol. 2008;81(968):653-658. J Nucl Med. 2014;55(8):1273-1280. 12. Doyle NM, Ramirez MM, Mastrobattista JM, Monga M, Wagner LK, Gardner MO. Diagnosis of 27. Revel MP, Cohen S, Sanchez O, et al. Pulmonary embolism during pregnancy: diagnosis with lung pulmonary embolism: a cost-effectiveness analysis. Am J Obstet Gynecol. 2004;191(3):1019-1023. scintigraphy or CT angiography? Radiology. 2011;258(2):590-598. 13. Ezwawah O, Alkoteesh J, Barry JE, Ryan M. Pulmonary embolism in pregnancy: is nuclear medicine 28. Ridge CA, McDermott S, Freyne BJ, Brennan DJ, Collins CD, Skehan SJ. Pulmonary embolism in still a valid option? Ir Med J. 2008;101(9):281-284. pregnancy: Comparison of pulmonary CT angiography and lung scintigraphy. AJR Am J Roentgenol. 2009;193(5):1223-1227. 14. Forbes KP, Reid JH, Murchison JT. Do preliminary chest X-ray findings define the optimum role of pulmonary scintigraphy in suspected pulmonary embolism? Clin Radiol. 2001;56(5):397-400. 29. Scarsbrook AF, Bradley KM, Gleeson FV. Perfusion scintigraphy: diagnostic utility in pregnant women with suspected pulmonary embolic disease. Eur Radiol. 2007;17(10):2554-2560. 15. Grüning T, Mingo RE, Gosling MG, et al. Diagnosing venous thromboembolism in pregnancy. Br J Radiol. 2016;89(1062):20160021. 30. Shahir K, Goodman LR, Tali A, Thorsen KM, Hellman RS. Pulmonary embolism in pregnancy: CT pulmonary angiography versus perfusion scanning. AJR Am J Roentgenol. 2010;195(3):W214-W220. 16. Hurwitz LM, Yoshizumi T, Reiman RE, et al. Radiation dose to the fetus from body MDCT during early gestation. AJR Am J Roentgenol. 2006;186(3):871-876. 31. U-King-Im JM, Freeman SJ, Boylan T, Cheow HK. Quality of CT pulmonary angiography for suspected pulmonary embolus in pregnancy. Eur Radiol. 2008;18(12):2709-2715. 17. Konstantinides SV, Meyer g, Becattini C, et al. 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Society 32. van Mens TE, Scheres LJ, de Jong PG, Leeflang MM, Nijkeuter M, Middeldorp S. Imaging for the (ERS). Eur Heart J. 2020;41(4):543-603. exclusion of pulmonary embolism in pregnancy. Cochrane database Syst Rev. 2017;1:CD011053. doi:10.1002/14651858.CD011053. 18. Leung AN, Bull TM, Jaeschke R, et al; ATS/STR Committee on Pulmonary Embolism in Pregnancy. An official American Thoracic Society/Society of Thoracic Radiology clinical practice guideline: evaluation 33. van der Pol LM, Tromeur C, Bistervels IM, et al. Pregnancy-Adapted YEARS Algorithm for diagnosis of of suspected pulmonary embolism in pregnancy. Am J Respir Crit Care Med. 2011;184(10):1200-1208. suspected pulmonary embolism. N Engl J Med. 2019;380(12):1139-1149. 19. Linet MS, Kim KP, Rajaraman P. Children’s exposure to diagnostic medical radiation and cancer risk: 34. Wang PI, Chong ST, Kielar AZ, et al. Imaging of pregnant and lactating patients: part 2, evidence- epidemiologic and dosimetric considerations. Pediatr Radiol. 2009;39 Suppl 1:S4-26. based review and recommendations. AJR Am J Roentgenol. 2012;198(4):785-792. 20. Litmanovich D, Boiselle PM, Bankier AA, Kataoka ML, Pianykh O, Raptopoulos V. Dose reduction in 35. Winer-Muram HT, Boone JM, Brown HL, Jennings SG, Mabie WC, Lombardo GT. Pulmonary computed tomographic angiography of pregnant patients with suspected acute pulmonary embolism. embolism in pregnant patients: fetal radiation dose with helical CT. Radiology. 2002;224(2):487–492. J Comput Assist Tomogr 2009; 33: 961-966. 21. McCollough CH, Schueler BA, Atwell TD, et al. Radiation exposure and pregnancy: When should we be concerned? Radiographics. 2007;27(4):909–917. 22. Niemann T, Nicolas G, Roser HW, Müller-Brand J, Bongartz G. Imaging for suspected pulmonary embolism in pregnancy — what about the fetal dose? A comprehensive review of the literature. Insights Imaging. 2010;1(5-6):361-372.

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Development Group

REFERENCES (from pages 1 through 3) • Jordan Albritton, PhD, MPH • Joseph Bledsoe, MD ACR American College of Radiology. ACR Appropriateness Criteria® Radiation Dose Assessment Introduction. https://www .acr .org/-/media/ACR/ Files/Appropriateness-Criteria/RadiationDoseAssessmentIntro .pdf . Accessed July 26, 2017. • Terry Clemmer, MD CMS1 Centers for Medicare & Medicaid Services (CMS). Medicare claims data set. https://www .cms .gov/Medicare/Quality-Initiatives-Patient- • Karen Conner, MD, MBA Assessment-Instruments/Appropriate-Use-Criteria-Program/data .html. Published 2016. Accessed June 27, 2017. • Greg Elliott, MD CMS2 Centers for Medicare & Medicaid Services (CMS). Physician fee schedule. https://www .cms .gov/Medicare/Medicare-Fee-for-Service- • James Hellewell, MD Payment/PhysicianFeeSched/ . Published July 17, 2017. Accessed August 8, 2017. • David Jackson, MPH (Medical Writer) FRY Fryback DG, Thornbury JR. The efficacy of diagnostic imaging.Med Decis Making 1991;11(2):88-94. • Kathryn Kuttler GAO United States Government Accountability Office (GAO). Medicare Part B imaging services: Rapid spending growth and shift to physician offices indicate need for CMS to consider additional management practices. 2008;(GAO-08-452). http://www .gao .gov/products/GAO-08- • Nancy Nelson, RN, MS 452. Accessed June 13, 2017. • Ann Phan, MBA HPS Health Physics Society. Radiation Exposure from Medical Exams and Procedures: Fact Sheet. https://hps .org/documents/Medical_ • Scott Stevens, MD Exposures_Fact_Sheet .pdf. Accessed July 31, 2017. • Keith White, MD IGL Iglehart JK. Health insurers and medical-imaging policy — A work in progress. N Engl J Med. 2009;360(10):1030-1037. • Scott Woller, MD LEV Levin DC, Parker L, Palit CD, Rao VM. After nearly a decade of rapid growth, use and complexity of imaging declined, 2008-14. Health Aff (Millwood). 2017;36(4):663-670. NYDH New York State Department of Health (NYDH). Advanced diagnostic imaging: Background on use, patient safety, costs and implications for the health care industry definition of advanced medical imaging. https://www .health .ny .gov/facilities/public_health_and_health_planning_ council/meetings/2013-07-17/docs/2013-07-03_adv_diag_imag_backgrnd_papers .pdf. Accessed June 21, 2017. OCE OCEBM Levels of Evidence Working Group; Oxford Centre for Evidence-Based Medicine. The Oxford 2011 Levels of Evidence. http://www .cebm .net/index .aspx?o=5653. Accessed July 31, 2017. SMI Smith-Bindman R, Miglioretti DL, Johnson E, et al. Use of diagnostic imaging studies and associated radiation exposure for patients enrolled in large integrated health care systems, 1996-2010. JAMA. 2012;307(22):2400-2409.

This CPM presents a model of best care based on the best available scientific evidence at the time of publication. It is not a prescription for every physician or every patient, nor does it replace clinical judgment. All statements, protocols, and recommendations herein are viewed as transitory and iterative. Although physicians are encouraged to follow the CPM to help focus on and measure quality, deviations are a means for discovering improvements in patient care and expanding the knowledge base.

© 2017 Intermountain Intellectual Asset Management, LLC, a wholly owned subsidiary of Intermountain Healthcare. All rights reserved. Intermountain Healthcare developed and endorses the Appropriate Use Criteria contained in this Care Process Model as a Provider-Led Entity qualified by the Centers for Medicare and Medicaid Services. Patient and Provider Publications CPM3008 - 09/20 13