An electronic alert doubled pulmonary hypertension screening in symptomatic patients after PE

Design

Quasi-cluster randomised trial of an electronic decision-support alert

Population

400 outpatients ≥6 months after PE with symptoms or abnormal tests, under 73 physicians

Primary outcome

Echocardiographic screening within 90 days

Effect

32.5% vs 17.5% (aOR 2.23, 95% CI 1.58–3.15); pulmonary hypertension found 10.5% vs 5.0%

CTEPH-DETECT was a quasi-cluster randomised trial in outpatients at least six months after a pulmonary embolism, with persistent or new symptoms or unexplained abnormal tests, and no echocardiogram in the previous six months. 73 physicians caring for 400 such patients were assigned to receive an electronic alert recommending an echocardiogram, or no alert.

Echocardiography within 90 days was ordered for 32.5% with the alert against 17.5% without (adjusted OR 2.23). New pulmonary hypertension on echo was found in 10.5% against 5.0%. No patient received a formal diagnosis of chronic thromboembolic pulmonary hypertension in either group during the study.

The value of the trial is in showing how often a symptomatic patient after PE goes unscreened. Even with the alert, two-thirds did not have an echo. Patient outcomes were not measured, and the absence of any new CTEPH diagnosis means it is not yet clear the extra scans changed anyone's course.

• Ask about breathlessness and exercise tolerance at every review from three months after a pulmonary embolism.
• Consider echocardiography for patients with persistent or new symptoms after PE, as current practice already recommends.
• Use a recall or flag in your own clinic system; without prompting, most eligible patients went unscreened.
• Refer suspected pulmonary hypertension after PE for ventilation-perfusion scanning, which is the screening test for CTEPH.
• Do not attribute persistent breathlessness after PE to deconditioning without excluding pulmonary hypertension.

Why it matters

It shows that symptomatic patients after PE are usually not screened unless someone is reminded.

Don't overread it

The trial measured scans ordered and pulmonary hypertension found, not whether patients did better.

The statistics, in plain English

An adjusted odds ratio of 2.23 (95% CI 1.58–3.15) means the alert roughly doubled the odds of an echo being ordered. Because physicians rather than patients were randomised and the design was 'quasi' randomised, the groups may differ in ways the analysis could not adjust for.

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