Impact of emergency physician experience on decision-making in patients with suspected community-acquired pneumonia and undergoing systematic thoracic CT scan

Josselin Le Bel, Thierry Pelaccia, Patrick Ray, Charles Mayaud, Anne-Laure Brun, Pierre Hausfater, Enrique Casalino, Mikhael Benjoar, Yann-Erick Claessens, Xavier Duval, ESCAPED study group, Y E Claessens, X Duval, E Bouvard, M F Carette, M P Debray, C Mayaud, C Leport, N Houhou, S Tubiana, M Benjoar, X Blanc, A L Brun, L Epelboin, C Ficko, A Khalil, H Lefloch, J M Naccache, B Rammaert, A Abry, J C Allo, S Andre, C Andreotti, N Baarir, M Bendahou, L Benlafia, J Bernard, A Berthoumieu, M E Billemont, J Bokobza, A L Brun, E Burggraff, P Canavaggio, M F Carette, E Casalino, S Castro, C Choquet, H Clément, L Colosi, A Dabreteau, S Damelincourt, S Dautheville, M P Debray, M Delay, S Delerme, L Depierre, F Djamouri, F Dumas, M R S Fadel, A Feydey, Y Freund, L Garcia, H Goulet, P Hausfater, E Ilic-Habensus, M O Josse, J Kansao, Y Kieffer, F Lecomte, K Lemkarane, P Madonna, O Meyniard, L Mzabi, D Pariente, J Pernet, F Perruche, J M Piquet, R Ranerison, P Ray, F Renai, E Rouff, D Saget, K Saïdi, G Sauvin, E Trabattoni, N Trimech, Josselin Le Bel, Thierry Pelaccia, Patrick Ray, Charles Mayaud, Anne-Laure Brun, Pierre Hausfater, Enrique Casalino, Mikhael Benjoar, Yann-Erick Claessens, Xavier Duval, ESCAPED study group, Y E Claessens, X Duval, E Bouvard, M F Carette, M P Debray, C Mayaud, C Leport, N Houhou, S Tubiana, M Benjoar, X Blanc, A L Brun, L Epelboin, C Ficko, A Khalil, H Lefloch, J M Naccache, B Rammaert, A Abry, J C Allo, S Andre, C Andreotti, N Baarir, M Bendahou, L Benlafia, J Bernard, A Berthoumieu, M E Billemont, J Bokobza, A L Brun, E Burggraff, P Canavaggio, M F Carette, E Casalino, S Castro, C Choquet, H Clément, L Colosi, A Dabreteau, S Damelincourt, S Dautheville, M P Debray, M Delay, S Delerme, L Depierre, F Djamouri, F Dumas, M R S Fadel, A Feydey, Y Freund, L Garcia, H Goulet, P Hausfater, E Ilic-Habensus, M O Josse, J Kansao, Y Kieffer, F Lecomte, K Lemkarane, P Madonna, O Meyniard, L Mzabi, D Pariente, J Pernet, F Perruche, J M Piquet, R Ranerison, P Ray, F Renai, E Rouff, D Saget, K Saïdi, G Sauvin, E Trabattoni, N Trimech

Abstract

Objectives: To determine whether the impact of a thoracic CT scan on community-acquired pneumonia (CAP) diagnosis and patient management varies according to emergency physician's experience (≤10 vs >10 years).

Methods: Early thoracic CT Scan for Community-Acquired Pneumonia at the Emergency Department is an interventional study conducted from November 2011 to January 2013 in four French emergency departments, and included suspected patients with CAP. We analysed changes in emergency physician CAP diagnosis classification levels before and after CT scan; and their agreement with an adjudication committee. We performed univariate analysis to determine the factors associated with modifying the diagnosis classification level to be consistent with the radiologist's CT scan interpretation.

Results: 319 suspected patients with CAP and 136 emergency physicians (75% less experienced with ≤10 years, 25% with >10 years of experience) were included. The percentage of patients whose classification was modified to become consistent with CT scan radiologist's interpretation was higher among less-experienced than experienced emergency physicians (54.2% vs 40.2%; p=0.02). In univariate analysis, less emergency physician experience was the only factor associated with changing a classification to be consistent with the CT scan radiologist's interpretation (OR 1.77, 95% CI 1.01 to 3.10, p=0.04). After CT scan, the agreement between emergency physicians and adjudication committee was moderate for less-experienced emergency physicians and slight for experienced emergency physicians (k=0.457 and k=0.196, respectively). After CT scan, less-experienced emergency physicians modified patient management significantly more than experienced emergency physicians (36.1% vs 21.7%, p=0.01).

Conclusions: In clinical practice, less-experienced emergency physicians were more likely to accurately modify their CAP diagnosis and patient management based on thoracic CT scan than more experienced emergency physicians.

Trial registration number: NCT01574066.

Keywords: emergency care systems, advanced practitioner; emergency care systems, emergency departments; imaging, Ct/mri; pneumonia/infections.

Conflict of interest statement

Competing interests: JLB reports grants from Pfizer, outside the submitted work. Y-EC reports grants from the French Ministry of Health, during the conduct of the study, and reports grants from Biomerieux, Sanofi and Bayer, outside the submitted work. XD reports grants from the French Ministry of Health, during the conduct of the study, and reports grants from Pfizer, outside the submitted work.

© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

Figures

Figure 1
Figure 1
Level of CAP diagnosis classification: evaluation of agreement between emergency physicians classification and radiologists’ classification or adjudication committee classification before and after thoracic CT scan. CAP, community-acquired pneumonia.
Figure 2
Figure 2
Patients classification before and after thoracic CT scan according to CT scan interpretation by radiologist.

References

    1. Croskerry P. Critical thinking and decisionmaking: avoiding the perils of thin-slicing. Ann Emerg Med 2006;48:720–2. 10.1016/j.annemergmed.2006.03.030
    1. Gennis P, Gallagher J, Falvo C, et al. . Clinical criteria for the detection of pneumonia in adults: guidelines for ordering chest roentgenograms in the emergency department. J Emerg Med 1989;7:263–8. 10.1016/0736-4679(89)90358-2
    1. Metlay JP, Fine MJ. Testing strategies in the initial management of patients with community-acquired pneumonia. Ann Intern Med 2003;138:109–18. 10.7326/0003-4819-138-2-200301210-00012
    1. Mandell LA. Epidemiology and etiology of community-acquired pneumonia. Infect Dis Clin North Am 2004;18:761–76. 10.1016/j.idc.2004.08.003
    1. Albaum MN, Hill LC, Murphy M, et al. . Interobserver reliability of the chest radiograph in community-acquired pneumonia. PORT Investigators. Chest 1996;110:343–50. 10.1378/chest.110.2.343
    1. Hopstaken RM, Witbraad T, van Engelshoven JM, et al. . Inter-observer variation in the interpretation of chest radiographs for pneumonia in community-acquired lower respiratory tract infections. Clin Radiol 2004;59:743–52. 10.1016/j.crad.2004.01.011
    1. Claessens YE, Debray MP, Tubach F, et al. . Early chest computed tomography scan to assist diagnosis and guide treatment decision for suspected community-acquired pneumonia. Am J Respir Crit Care Med 2015;192:974–82. 10.1164/rccm.201501-0017OC
    1. Upchurch CP, Grijalva CG, Wunderink RG, et al. . Community-acquired pneumonia visualized on CT scans but not chest radiographs: pathogens, severity, and clinical outcomes. Chest 2018;153:601–10. 10.1016/j.chest.2017.07.035
    1. Prendki V, Scheffler M, Huttner B, et al. . Low-dose computed tomography for the diagnosis of pneumonia in elderly patients: a prospective, interventional cohort study. Eur Respir J 2018;51:1702375 10.1183/13993003.02375-2017
    1. Self WH, Courtney DM, McNaughton CD, et al. . High discordance of chest x-ray and computed tomography for detection of pulmonary opacities in ED patients: implications for diagnosing pneumonia. Am J Emerg Med 2013;31:401–5. 10.1016/j.ajem.2012.08.041
    1. Schubert CC, Denmark TK, Crandall B, et al. . Characterizing novice-expert differences in macrocognition: an exploratory study of cognitive work in the emergency department. Ann Emerg Med 2013;61:96–109. 10.1016/j.annemergmed.2012.08.034
    1. Bauer TT, Ewig S, Marre R, et al. . CRB-65 predicts death from community-acquired pneumonia. J Intern Med 2006;260:93–101. 10.1111/j.1365-2796.2006.01657.x
    1. Ericsson KA. Deliberate practice and the acquisition and maintenance of expert performance in medicine and related domains. Acad Med 2004;79(10 Suppl):S70–81. 10.1097/00001888-200410001-00022
    1. Croskerry P, Sinclair D. Emergency medicine: a practice prone to error? CJEM 2001;3:271–6. 10.1017/S1481803500005765
    1. Metlay JP, Schulz R, Li YH, et al. . Influence of age on symptoms at presentation in patients with community-acquired pneumonia. Arch Intern Med 1997;157:1453–9. 10.1001/archinte.1997.00440340089009
    1. Fine MJ, Auble TE, Yealy DM, et al. . A prediction rule to identify low-risk patients with community-acquired pneumonia. N Engl J Med 1997;336:243–50. 10.1056/NEJM199701233360402
    1. Abujudeh HH, Kaewlai R, McMahon PM, et al. . Abdominopelvic CT increases diagnostic certainty and guides management decisions: a prospective investigation of 584 patients in a large academic medical center. AJR Am J Roentgenol 2011;196:238–43. 10.2214/AJR.10.4467
    1. Pandharipande PV, Reisner AT, Binder WD, et al. . CT in the emergency department: a real-time study of changes in physician decision making. Radiology 2016;278:812–21. 10.1148/radiol.2015150473
    1. Pandharipande PV, Alabre CI, Coy DL, et al. . Changes in physician decision making after CT: a prospective multicenter study in primary care settings. Radiology 2016;281:835–46. 10.1148/radiol.2016152887
    1. Pelaccia T, Tardif J, Triby E, et al. . From context comes expertise: how do expert emergency physicians use their know-who to make decisions? Ann Emerg Med 2016;67:747–51. 10.1016/j.annemergmed.2015.07.023
    1. Halm EA, Atlas SJ, Borowsky LH, et al. . Understanding physician adherence with a pneumonia practice guideline: effects of patient, system, and physician factors. Arch Intern Med 2000;160:98–104.
    1. Baloescu C. Diagnostic imaging in emergency medicine: how much is too much? Ann Emerg Med 2018;72:637–43. 10.1016/j.annemergmed.2018.06.034
    1. Blumenthal-Barby JS, Krieger H. Cognitive biases and heuristics in medical decision making: a critical review using a systematic search strategy. Med Decis Making 2015;35:539–57. 10.1177/0272989X14547740

Source: PubMed

Sponsors and Collaborators

Medical Conditions

Drug Interventions

3
Subscribe