In this cohort study of 4,180,159 ED visits and 747 clinicians, variation in the first decision moment—the decision to test for PE—was associated with diagnostic yield, and future research should target standardizing this most upstream decision to best improve diagnostic quality.
Key Findings
Results
Clinicians in the lowest-testing quintile had significantly higher CTPA diagnostic yield compared to clinicians in the highest-testing quintile.
Pooled CTPA yield for the lowest-testing quintile was 9.6% (95% CI, 9.0%-10.1%)
Pooled CTPA yield for the highest-testing quintile was 6.4% (95% CI, 5.5%-7.3%)
The difference in yield was -3.2 percentage points (95% CI, -4.2 to -2.1 percentage points)
Diagnostic yield was associated with the decision to test for PE and the decision on initial testing modality
Results
Potential missed opportunities to diagnose PE were rare but were associated with lower testing intensity.
189 potential missed opportunities to diagnose PE were identified out of 13,530 acute cases
This represents 1.4% of PEs identified in the cohort
Missed opportunities were defined using 10-day ED revisits and symptom-disease pair analysis
Lower testing intensity was associated with these potential missed diagnoses
Methods
The study evaluated three distinct decision moments in PE diagnostic workup across 29 Michigan emergency departments.
Decision moment 1: the decision to test for PE (proportion of visits with either a D-dimer assay or CTPA performed)
Decision moment 2: the decision on initial testing modality (proportion of tested visits with CTPA performed without D-dimer assay first)
Decision moment 3: the decision on interpreting the negative D-dimer result (proportion of negative age-adjusted visits that proceeded from D-dimer assay to CTPA)
The study included ED visits from January 1, 2023, to November 30, 2025
Methods
The study included a large, diverse cohort of ED visits and clinicians across 29 Michigan emergency departments.
Total sample included 4,180,159 ED visits
Median patient age was 52 years (IQR, 34-69 years); 55.8% female (2,334,043 visits)
747 ED clinicians were included, 62.0% male (463 clinicians)
Median clinician graduation year was 2013 (IQR, 2006-2017)
Discussion
The first decision moment—whether to test for PE at all—was identified as the most important upstream target for improving diagnostic quality.
Diagnostic yield was specifically associated with the decision to test for PE and the decision on initial testing modality
The decision on interpreting negative D-dimer results (third decision moment) was not highlighted as significantly associated with yield differences
Authors conclude that future research should target standardizing the most upstream decision
Overtesting with CTPA is described as an established quality improvement target in emergency departments
What This Means
This research studied how emergency department (ED) doctors in Michigan decide whether and how to test patients for pulmonary embolism (PE)—a potentially life-threatening blood clot in the lungs. The main test used to definitively diagnose PE is a CT scan of the lungs (called CTPA), but ordering too many of these scans is considered a quality problem because it exposes patients to radiation and contrast dye unnecessarily. The study examined over 4 million ED visits across 29 hospitals and tracked the decisions of 747 clinicians, breaking the diagnostic process into three key moments: deciding whether to test at all, deciding which test to start with, and deciding whether to proceed to a CT scan after a negative blood test (D-dimer).
The study found that doctors who tested fewer patients for PE had a higher 'diagnostic yield'—meaning a greater proportion of their CT scans actually found a PE (9.6% vs. 6.4% for the highest-testing doctors). This suggests that some clinicians are ordering CT scans for patients who are unlikely to have PE, which reduces the overall usefulness of testing. The researchers also found 189 cases (about 1.4% of all PE diagnoses) where a PE may have been missed, and these were more common among lower-testing clinicians, suggesting that undertesting also carries risks.
This research suggests that the most impactful place to improve PE diagnosis in emergency departments is the very first decision—whether to begin testing at all—rather than later steps in the process like which test to order first or how to interpret results. Standardizing how doctors make this initial decision could potentially reduce unnecessary CT scans while also catching more cases that might otherwise be missed.
Janke A, Fung C, Bombard M, Krupp S, Oostema J, Overbeek D, et al.. (2026). Decision Moments and Pulmonary Embolism Diagnostic Quality in the Emergency Department.. JAMA network open. https://doi.org/10.1001/jamanetworkopen.2026.35312