OBJECTIVES: Use of pretest probability can reduce unnecessary testing. We hypothesize that quantitative pretest probability, linked to evidence-based management strategies, can reduce unnecessary radiation exposure and cost in low-risk patients with symptoms suggestive of acute coronary syndrome (ACS) and pulmonary embolism (PE).
METHODS: Prospective, four-center, randomized controlled trial of decision support effectiveness. Subjects were adults with chest pain and dyspnea, non-diagnostic electrocardiograms and no obvious diagnosis. The clinician provided data needed to compute pretest probabilities from a web-based system. Clinicians randomized to the intervention group received the pretest probability estimates for both ACS and PE and suggested clinical actions designed to lower radiation exposure and cost. The control group received nothing. Patients were followed for 90 days. The primary outcome and sample size of 550 was predicated on a significant reduction in the proportion of healthy patients exposed to > 5 mSv chest radiation. 550 patients were randomized and 541 had complete data.
RESULTS: The proportion with >5 mSv to the chest was and no significant cardiopulmonary diagnosis within 90 days was reduced from 33% to 25% (P=0.038). The intervention group had significantly lower median chest radiation exposure (0.06 mSv versus 0.34 mSv, P=0.037, Mann Whitney U test) and lower median costs ($934 versus $1275, P=0.018) for medical care. Adverse events occurred in 16% of controls and 11% in the intervention group (P=0.06).
CONLCUSIONS: Provision of pretest probability and prescriptive advice reduced radiation exposure and cost of care in low-risk ambulatory patients with symptoms of ACS and PE.