{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,22]],"date-time":"2026-09-22T15:59:25Z","timestamp":1790092765098,"version":"4.0.1"},"reference-count":34,"publisher":"American Medical Association (AMA)","issue":"9","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JAMA Netw Open"],"abstract":"\n Importance<\/jats:title>\n Overtesting with computed tomographic pulmonary angiography (CTPA) to diagnose pulmonary embolism (PE) is a quality improvement target in emergency departments (EDs).<\/jats:p>\n <\/jats:sec>\n \n Objective<\/jats:title>\n To describe how ED clinicians vary in their diagnostic practices for PE, specific to key decision moments, and how these practices are associated with CTPA diagnostic yield, the primary modality for definitively diagnosing PE, as well as potential missed opportunities to diagnose.<\/jats:p>\n <\/jats:sec>\n \n Design, Setting, and Participants<\/jats:title>\n This retrospective cohort study included ED visits and clinicians at 29 Michigan EDs from January 1, 2023, to November 30, 2025. ED visits were stratified by clinician\u2019s diagnostic practices.<\/jats:p>\n <\/jats:sec>\n \n Exposures<\/jats:title>\n Three decision moments were evaluated: (1) the decision to test for PE (proportion of visits with either a D-dimer assay or CTPA performed); (2) the decision on initial testing modality (proportion of tested visits with CTPA performed without D-dimer assay first); and (3) the decision on interpreting the negative D-dimer result (proportion of negative age-adjusted visits that proceeded from D-dimer assay to CTPA).<\/jats:p>\n <\/jats:sec>\n \n Main Outcomes and Measures<\/jats:title>\n Diagnostic yield was defined as the percentage of CTPAs used to diagnose an acute PE. Potential missed opportunities to diagnose PE were defined using 10-day ED revisits and symptom-disease pair analysis.<\/jats:p>\n <\/jats:sec>\n \n Results<\/jats:title>\n The sample included 4 180 159 ED visits (median patient age, 52 [IQR, 34-69] years; 2\u202f334\u202f043 [55.8%] female) and 747 ED clinicians (463 [62.0%] male; median graduation year, 2013 [IQR, 2006-2017]). Diagnostic yield was associated with diagnostic practices at the decision to test for PE and the decision on initial testing modality. The decision to test for PE showed a pooled CTPA yield for the lowest-testing quintile of clinicians of 9.6% (95% CI, 9.0%-10.1%), while the corresponding yield for the highest-testing quintile was 6.4% (95% CI, 5.5%-7.3%; difference, \u22123.2 percentage points [95% CI, \u22124.2 to \u22122.1 percentage points]). A total of 189 potential missed opportunities to diagnose PE of 13\u202f530 acute cases (1.4% of PEs) were identified, and these were associated with lower testing intensity.<\/jats:p>\n <\/jats:sec>\n \n Conclusions and Relevance<\/jats:title>\n In this cohort study of 4\u202f180\u202f159 ED visits and 747 clinicians, variation in the first decision moment, the decision to test for PE, was associated with diagnostic yield. Future research should target standardizing this most upstream decision to best improve diagnostic quality.<\/jats:p>\n <\/jats:sec>","DOI":"10.1001\/jamanetworkopen.2026.35312","type":"journal-article","created":{"date-parts":[[2026,9,22]],"date-time":"2026-09-22T15:00:25Z","timestamp":1790089225000},"page":"e2635312","source":"Crossref","is-referenced-by-count":0,"title":["Decision Moments and Pulmonary Embolism Diagnostic Quality in the Emergency Department"],"prefix":"10.1001","volume":"9","author":[{"given":"Alexander T.","family":"Janke","sequence":"first","affiliation":[{"name":"Department of Emergency Medicine, University of Michigan, Ann Arbor"},{"name":"Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Christopher M.","family":"Fung","sequence":"additional","affiliation":[{"name":"Department of Emergency Medicine, University of Michigan, Ann Arbor"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Matthew C.","family":"Bombard","sequence":"additional","affiliation":[{"name":"Department of Emergency Medicine, Western Michigan University Homer Stryker MD School of Medicine, Kalamazoo"},{"name":"Department of Emergency Medicine, Michigan State University College of Osteopathic Medicine, East Lansing"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Seth","family":"Krupp","sequence":"additional","affiliation":[{"name":"Department of Emergency Medicine, Henry Ford Health, Detroit, Michigan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"J. Adam","family":"Oostema","sequence":"additional","affiliation":[{"name":"Department of Emergency Medicine, Michigan State University College of Human Medicine, Grand Rapids"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Daniel L.","family":"Overbeek","sequence":"additional","affiliation":[{"name":"J.S. Held LLC, Bingham Farms, Michigan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Matthew","family":"Hysell","sequence":"additional","affiliation":[{"name":"Department of Emergency Medicine, Corewell-Lakeland, St Joseph, Michigan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"James H.","family":"Paxton","sequence":"additional","affiliation":[{"name":"Department of Emergency Medicine, Wayne State University, Detroit, Michigan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Giuseppe","family":"Perrotta","sequence":"additional","affiliation":[{"name":"Department of Emergency Medicine, Henry Ford Health, Detroit, Michigan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Brett","family":"Todd","sequence":"additional","affiliation":[{"name":"Department of Emergency Medicine, Oakland University William Beaumont School of Medicine, Royal Oak, Michigan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Lauren M.","family":"Westafer","sequence":"additional","affiliation":[{"name":"Department of Emergency Medicine, UMass Chan Medical School\u2013Baystate, Springfield"},{"name":"Department of Healthcare Delivery and Population Science, UMass Chan Medical School\u2013Baystate, Springfield"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Geoffrey D.","family":"Barnes","sequence":"additional","affiliation":[{"name":"Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor"},{"name":"Frankel Cardiovascular Center, Department of Internal Medicine, University of Michigan, Ann Arbor"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Colin F.","family":"Greineder","sequence":"additional","affiliation":[{"name":"Department of Emergency Medicine, University of Michigan, Ann Arbor"},{"name":"Department of Pharmacology, University of Michigan, Ann Arbor"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Keith E.","family":"Kocher","sequence":"additional","affiliation":[{"name":"Department of Emergency Medicine, University of Michigan, Ann Arbor"},{"name":"Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor"},{"name":"Department of Learning Health Sciences, University of Michigan, Ann Arbor"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"10","published-online":{"date-parts":[[2026,9,22]]},"reference":[{"issue":"3","key":"zoi260949r1","doi-asserted-by":"publisher","first-page":"394","DOI":"10.1016\/j.annemergmed.2023.01.019","article-title":"Managing pulmonary embolism.","volume":"82","author":"Westafer","year":"2023","journal-title":"Ann Emerg Med"},{"issue":"1","key":"zoi260949r2","doi-asserted-by":"publisher","first-page":"104","DOI":"10.1016\/j.jemermed.2014.12.041","article-title":"Emergency evaluation for pulmonary embolism, part 2: diagnostic approach.","volume":"49","author":"Kline","year":"2015","journal-title":"J Emerg Med"},{"issue":"8","key":"zoi260949r3","doi-asserted-by":"publisher","first-page":"1247","DOI":"10.1111\/j.1538-7836.2004.00790.x","article-title":"Clinical criteria to prevent unnecessary diagnostic testing in emergency department patients with suspected pulmonary embolism.","volume":"2","author":"Kline","year":"2004","journal-title":"J Thromb Haemost"},{"issue":"5","key":"zoi260949r4","doi-asserted-by":"publisher","first-page":"772","DOI":"10.1111\/j.1538-7836.2008.02944.x","article-title":"Prospective multicenter evaluation of the pulmonary embolism rule-out criteria.","volume":"6","author":"Kline","year":"2008","journal-title":"J Thromb Haemost"},{"issue":"2","key":"zoi260949r5","doi-asserted-by":"publisher","first-page":"98","DOI":"10.7326\/0003-4819-135-2-200107170-00010","article-title":"Excluding pulmonary embolism at the bedside without diagnostic imaging: management of patients with suspected pulmonary embolism presenting to the emergency department by using a simple clinical model and D-dimer.","volume":"135","author":"Wells","year":"2001","journal-title":"Ann Intern Med"},{"issue":"5","key":"zoi260949r6","doi-asserted-by":"publisher","first-page":"503","DOI":"10.1016\/j.annemergmed.2004.04.002","article-title":"Prospective validation of Wells criteria in the evaluation of patients with suspected pulmonary embolism.","volume":"44","author":"Wolf","year":"2004","journal-title":"Ann Emerg Med"},{"issue":"1","key":"zoi260949r7","doi-asserted-by":"publisher","first-page":"229","DOI":"10.1160\/TH07-05-0321","article-title":"Further validation and simplification of the Wells clinical decision rule in pulmonary embolism.","volume":"99","author":"Gibson","year":"2008","journal-title":"Thromb Haemost"},{"issue":"6","key":"zoi260949r8","doi-asserted-by":"publisher","first-page":"517","DOI":"10.1016\/j.annemergmed.2011.10.022","article-title":"Diagnostic accuracy of pulmonary embolism rule-out criteria: a systematic review and meta-analysis.","volume":"59","author":"Singh","year":"2012","journal-title":"Ann Emerg Med"},{"issue":"13","key":"zoi260949r9","doi-asserted-by":"publisher","first-page":"1028","DOI":"10.1001\/archinternmed.2012.1804","article-title":"Evaluation of pulmonary embolism in the emergency department and consistency with a national quality measure: quantifying the opportunity for improvement.","volume":"172","author":"Venkatesh","year":"2012","journal-title":"Arch Intern Med"},{"issue":"11","key":"zoi260949r10","doi-asserted-by":"publisher","first-page":"1117","DOI":"10.1001\/jama.2014.2135","article-title":"Age-adjusted D-dimer cutoff levels to rule out pulmonary embolism: the ADJUST-PE study.","volume":"311","author":"Righini","year":"2014","journal-title":"JAMA"},{"issue":"13","key":"zoi260949r11","doi-asserted-by":"publisher","first-page":"1626","DOI":"10.1016\/j.jacc.2025.11.005","article-title":"AHA\/ACC\/ACCP\/ACEP\/CHEST\/SCAI\/SHM\/SIR\/SVM\/SVN guideline for the evaluation and management of acute pulmonary embolism in adults: a report of the American College of Cardiology\/American Heart Association Joint Committee on Clinical Practice Guidelines.","volume":"87","author":"Creager","year":"2026","journal-title":"J Am Coll Cardiol"},{"issue":"5","key":"zoi260949r12","doi-asserted-by":"publisher","first-page":"e59","DOI":"10.1016\/j.annemergmed.2018.03.006","article-title":"Clinical policy: critical issues in the evaluation and management of adult patients presenting to the emergency department with suspected acute venous thromboembolic disease.","volume":"71","author":"Wolf","year":"2018","journal-title":"Ann Emerg Med"},{"issue":"4","key":"zoi260949r13","doi-asserted-by":"publisher","first-page":"543","DOI":"10.1093\/eurheartj\/ehz405","article-title":"2019 ESC guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS).","volume":"41","author":"Konstantinides","year":"2020","journal-title":"Eur Heart J"},{"issue":"22","key":"zoi260949r14","doi-asserted-by":"publisher","first-page":"3226","DOI":"10.1182\/bloodadvances.2018024828","article-title":"American Society of Hematology 2018 guidelines for management of venous thromboembolism: diagnosis of venous thromboembolism.","volume":"2","author":"Lim","year":"2018","journal-title":"Blood Adv"},{"issue":"2","key":"zoi260949r15","doi-asserted-by":"publisher","first-page":"271","DOI":"10.2214\/AJR.14.13938","article-title":"Overdiagnosis of pulmonary embolism by pulmonary CT angiography.","volume":"205","author":"Hutchinson","year":"2015","journal-title":"AJR Am J Roentgenol"},{"issue":"11","key":"zoi260949r16","doi-asserted-by":"publisher","DOI":"10.1001\/jamanetworkopen.2020.26930","article-title":"Trends in imaging for suspected pulmonary embolism across US health care systems, 2004 to 2016.","volume":"3","author":"Wang","year":"2020","journal-title":"JAMA Netw Open"},{"issue":"9","key":"zoi260949r17","doi-asserted-by":"publisher","first-page":"701","DOI":"10.7326\/M14-1772","article-title":"Evaluation of patients with suspected acute pulmonary embolism: best practice advice from the Clinical Guidelines Committee of the American College of Physicians.","volume":"163","author":"Raja","year":"2015","journal-title":"Ann Intern Med"},{"issue":"2","key":"zoi260949r20","doi-asserted-by":"publisher","first-page":"139","DOI":"10.1001\/jama.2018.19509","article-title":"Rethinking how antibiotics are prescribed: incorporating the 4 moments of antibiotic decision making into clinical practice.","volume":"321","author":"Tamma","year":"2019","journal-title":"JAMA"},{"issue":"2","key":"zoi260949r21","doi-asserted-by":"publisher","first-page":"192","DOI":"10.1016\/j.annemergmed.2019.04.033","article-title":"Baseline performance of real-world clinical practice within a statewide emergency medicine quality network: the Michigan Emergency Department Improvement Collaborative (MEDIC).","volume":"75","author":"Kocher","year":"2020","journal-title":"Ann Emerg Med"},{"issue":"5","key":"zoi260949r22","doi-asserted-by":"publisher","first-page":"530","DOI":"10.1016\/j.annemergmed.2024.06.014","article-title":"Characterizing acute pulmonary embolism cases diagnosed at an emergency department revisit using a statewide clinical registry.","volume":"84","author":"Janke","year":"2024","journal-title":"Ann Emerg Med"},{"issue":"21","key":"zoi260949r23","doi-asserted-by":"publisher","first-page":"2141","DOI":"10.1001\/jama.2021.20750","article-title":"Effect of a diagnostic strategy using an elevated and age-adjusted D-dimer threshold on thromboembolic events in emergency department patients with suspected pulmonary embolism: a randomized clinical trial.","volume":"326","author":"Freund","year":"2021","journal-title":"JAMA"},{"issue":"22","key":"zoi260949r24","doi-asserted-by":"publisher","first-page":"2125","DOI":"10.1056\/NEJMoa1909159","article-title":"Diagnosis of pulmonary embolism with D-dimer adjusted to clinical probability.","volume":"381","author":"Kearon","year":"2019","journal-title":"N Engl J Med"},{"issue":"12","key":"zoi260949r25","doi-asserted-by":"publisher","first-page":"1139","DOI":"10.1056\/NEJMoa1813865","article-title":"Pregnancy-adapted YEARS algorithm for diagnosis of suspected pulmonary embolism.","volume":"380","author":"van der Pol","year":"2019","journal-title":"N Engl J Med"},{"issue":"10091","key":"zoi260949r26","doi-asserted-by":"publisher","first-page":"289","DOI":"10.1016\/S0140-6736(17)30885-1","article-title":"Simplified diagnostic management of suspected pulmonary embolism (the YEARS study): a prospective, multicentre, cohort study.","volume":"390","author":"van der Hulle","year":"2017","journal-title":"Lancet"},{"issue":"3","key":"zoi260949r27","doi-asserted-by":"publisher","first-page":"309","DOI":"10.1111\/acem.15075","article-title":"Exploring diagnostic stewardship in the emergency department evaluation of pediatric abdominal pain in a statewide quality collaborative.","volume":"32","author":"Janke","year":"2025","journal-title":"Acad Emerg Med"},{"issue":"12","key":"zoi260949r28","doi-asserted-by":"publisher","DOI":"10.1001\/jamanetworkopen.2023.46769","article-title":"Emergency department care for children during the 2022 viral respiratory illness surge.","volume":"6","author":"Janke","year":"2023","journal-title":"JAMA Netw Open"},{"issue":"3","key":"zoi260949r29","doi-asserted-by":"publisher","first-page":"99","DOI":"10.1016\/S1553-7250(14)40012-6","article-title":"Editorial: Helping health care organizations to define diagnostic errors as missed opportunities in diagnosis.","volume":"40","author":"Singh","year":"2014","journal-title":"Jt Comm J Qual Patient Saf"},{"issue":"7","key":"zoi260949r30","doi-asserted-by":"publisher","first-page":"557","DOI":"10.1136\/bmjqs-2017-007032","article-title":"Symptom-Disease Pair Analysis of Diagnostic Error (SPADE): a conceptual framework and methodological approach for unearthing misdiagnosis-related harms using big data.","volume":"27","author":"Liberman","year":"2018","journal-title":"BMJ Qual Saf"},{"issue":"1","key":"zoi260949r32","doi-asserted-by":"publisher","DOI":"10.1161\/CIRCOUTCOMES.119.005753","article-title":"Over-testing for suspected pulmonary embolism in American emergency departments: the continuing epidemic.","volume":"13","author":"Kline","year":"2020","journal-title":"Circ Cardiovasc Qual Outcomes"},{"issue":"1","key":"zoi260949r33","doi-asserted-by":"publisher","first-page":"173","DOI":"10.1111\/jth.15124","article-title":"Pulmonary embolism prevalence among emergency department cohorts: a systematic review and meta-analysis by country of study.","volume":"19","author":"Germini","year":"2021","journal-title":"J Thromb Haemost"},{"issue":"2","key":"zoi260949r34","doi-asserted-by":"publisher","first-page":"E38","DOI":"10.1503\/cmaj.201639","article-title":"Physician choices in pulmonary embolism testing.","volume":"193","author":"Zarabi","year":"2021","journal-title":"CMAJ"},{"key":"zoi260949r18","doi-asserted-by":"crossref","unstructured":"Newman-Toker? DE, Peterson? SM, Badihian? S, . Diagnostic errors in the emergency department: a systematic review. Agency for Healthcare Research and Quality. December 21, 2022. Accessed February 12, 2026. https:\/\/effectivehealthcare.ahrq.gov\/products\/diagnostic-errors-emergency-updated\/research","DOI":"10.23970\/AHRQEPCCER258"},{"key":"zoi260949r19","unstructured":"Four moments of antibiotic decision making. Agency for Healthcare Research and Quality. Reviewed November 2019. Accessed February 12, 2026. https:\/\/www.ahrq.gov\/antibiotic-use\/acute-care\/four-moments\/index.html."},{"key":"zoi260949r31","doi-asserted-by":"crossref","unstructured":"Normand? SLT, Shahian? DM. Statistical and clinical aspects of hospital outcomes profiling.? arXiv. Preprint posted online October 25, 2007. https:\/\/arxiv.org\/abs\/0710.4622.","DOI":"10.1214\/088342307000000096"}],"container-title":["JAMA Network Open"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/jamanetwork.com\/journals\/jamanetworkopen\/articlepdf\/2854317\/janke_2026_oi_260949_1789416854.50729.pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,9,22]],"date-time":"2026-09-22T15:00:28Z","timestamp":1790089228000},"score":1,"resource":{"primary":{"URL":"https:\/\/jamanetwork.com\/journals\/jamanetworkopen\/fullarticle\/2854317"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,9,22]]},"references-count":34,"journal-issue":{"issue":"9","published-print":{"date-parts":[[2026,9,1]]}},"URL":"https:\/\/doi.org\/10.1001\/jamanetworkopen.2026.35312","relation":{},"ISSN":["2574-3805"],"issn-type":[{"value":"2574-3805","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,9,22]]}}}