• Sahar Zarabi, Teresa M Chan, Mathew Mercuri, Clive Kearon, Michelle Turcotte, Emily Grusko, David Barbic, Catherine Varner, Eileen Bridges, Reaves Houston, Debra Eagles, and de WitKerstinKFaculty of Medicine (Zarabi, Varner) and Dalla Lana School of Public Health (Mercuri), University of Toronto, Toronto, Ont.; Faculty of Health Sciences (Chan, Mercuri, Kearon, de Wit), McMaster University, Hamilton, Ont.; Faculty of Medicine.
• Faculty of Medicine (Zarabi, Varner) and Dalla Lana School of Public Health (Mercuri), University of Toronto, Toronto, Ont.; Faculty of Health Sciences (Chan, Mercuri, Kearon, de Wit), McMaster University, Hamilton, Ont.; Faculty of Medicine (Turcotte, Eagles), University of Ottawa, Ottawa, Ont.; Faculty of Medicine (Grusko), University of Manitoba, Winnipeg, Man.; Faculty of Medicine (Barbic), University of British Columbia, Vancouver, BC; Faculty of Medicine (Bridges), McGill University, Montréal, Que.; Chapel Hill School of Medicine (Houston), University of North Carolina, Chapel Hill, NC.
• CMAJ. 2021 Jan 11; 193 (2): E38E46E38-E46.

BackgroundEvidence-based guidelines advise excluding pulmonary embolism (PE) diagnosis using d-dimer in patients with a lower probability of PE. Emergency physicians frequently order computed tomography (CT) pulmonary angiography without d-dimer testing or when d-dimer is negative, which exposes patients to more risk than benefit. Our objective was to develop a conceptual framework explaining emergency physicians' test choices for PE.MethodsWe conducted a qualitative study using in-depth interviews of emergency physicians in Canada. A nonmedical researcher conducted in-person interviews. Participants described how they would test simulated patients with symptoms of possible PE, answered a knowledge test and were interviewed on barriers to using evidence-based PE tests.ResultsWe interviewed 63 emergency physicians from 9 hospitals in 5 cities, across 3 provinces. We identified 8 domains: anxiety with PE, barriers to using the evidence (time, knowledge and patient), divergent views on evidence-based PE testing, inherent Wells score problems, the drive to obtain CT rather than to diagnose PE, gestalt estimation artificially inflating PE probability, subjective reasoning and cognitive biases supporting deviation from evidence-based tests and use of evidence-based testing to rule out PE in patients who are very unlikely to have PE. Choices for PE testing were influenced by the disease, environment, test qualities, physician and probability of PE.InterpretationAnalysis of structured interviews with emergency physicians provided a conceptual framework to explain how these physicians use tests for suspected PE. The data suggest 8 domains to address when implementing an evidence-based protocol to investigate PE.© 2021 Joule Inc. or its licensors.

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