[Skip to Content]
Access to paid content on this site is currently suspended due to excessive activity being detected from your IP address Please contact the publisher to request reinstatement.
[Skip to Content Landing]
Original Investigation
Less Is More
May 9, 2011

Time Trends in Pulmonary Embolism in the United States: Evidence of Overdiagnosis

Author Affiliations

Author Affiliations: The Pulmonary Center, Boston University School of Medicine, Boston, Massachusetts (Dr Wiener); Center for Health Quality, Outcomes, and Economic Research, Edith Nourse Rogers Memorial VA Hospital, Bedford, Massachusetts (Dr Wiener); VA Outcomes Group, Department of Veterans Affairs, White River Junction, Vermont (Drs Schwartz and Woloshin); and The Dartmouth Institute for Health Policy and Clinical Practice, and Departments of Medicine and Community & Family Medicine, Dartmouth Medical School, Hanover, New Hampshire (Drs Wiener, Schwartz, and Woloshin).

Arch Intern Med. 2011;171(9):831-837. doi:10.1001/archinternmed.2011.178

Background  Computed tomographic pulmonary angiography (CTPA) may improve detection of life-threatening pulmonary embolism (PE), but this sensitive test may have a downside: overdiagnosis and overtreatment (finding clinically unimportant emboli and exposing patients to harms from unnecessary treatment).

Methods  To assess the impact of CTPA on national PE incidence, mortality, and treatment complications, we conducted a time trend analysis using the Nationwide Inpatient Sample and Multiple Cause-of-Death databases. We compared age-adjusted incidence, mortality, and treatment complications (in-hospital gastrointestinal tract or intracranial hemorrhage or secondary thrombocytopenia) of PE among US adults before (1993-1998) and after (1998-2006) CTPA was introduced.

Results  Pulmonary embolism incidence was unchanged before CTPA (P = .64) but increased substantially after CTPA (81% increase, from 62.1 to 112.3 per 100 000; P < .001). Pulmonary embolism mortality decreased during both periods: more so before CTPA (8% reduction, from 13.4 to 12.3 per 100 000; P < .001) than after (3% reduction, from 12.3 to 11.9 per 100 000; P = .02). Case fatality improved slightly before (8% decrease, from 13.2% to 12.1%; P = .02) and substantially after CTPA (36% decrease, from 12.1% to 7.8%; P < .001). Meanwhile, CTPA was associated with an increase in presumed complications of anticoagulation for PE: before CTPA, the complication rate was stable (P = .24), but after it increased by 71% (from 3.1 to 5.3 per 100 000; P < .001).

Conclusions  The introduction of CTPA was associated with changes consistent with overdiagnosis: rising incidence, minimal change in mortality, and lower case fatality. Better technology allows us to diagnose more emboli, but to minimize harms of overdiagnosis we must learn which ones matter.