Variation in deciding to test for pulmonary embolism (PE) across emergency department (ED) clinicians was associated with diagnostic yield, according to a retrospective study recently published in JAMA Network Open.

Alexander T. Janke, MD, MHS, MSc, et al., included 4,180,159 visits (median age 52 years; 56% female) and 747 clinicians (median graduation year 2013; 62% male) at 29 Michigan EDs from Jan. 1, 2023, to Nov. 30, 2025. The authors investigated three decision moments: 1) the decision to test for PE, 2) the decision on initial testing modality and 3) the decision on interpreting the negative D-dimer result. A primary outcome of the study was diagnostic yield, determined by the percentage of CT pulmonary angiography (CTPA) used to diagnose an acute PE.

Results showed an association between diagnostic yield and both the decision to test for PE and the decision on testing modality. Comparing the lowest testing quintile of clinicians vs. the highest testing quintile of clinicians, decision to test for PE had a pooled CTPA yield of 9.6% vs. 6.4% (difference, −3.2 percentage points [95% CI, −4.2 to −2.1 percentage points]).

Out of 13,530 acute PE cases, there were 189 potential missed opportunities to diagnose, which were in turn associated with lower testing intensity. Missed opportunities were identified by 10-day ED revisits and symptom-disease pair analysis.

"Greater propensity to test was associated with lower risk of trade-off at this most upstream decision moment," write the authors. "To reduce overtesting and mitigate the risk of consequential misdiagnosis, future clinical research and quality improvement should target the first decision moment: which individuals should be tested for PE at all."