Consent to advanced imaging in antenatal pulmonary embolism diagnostics: Prevalence, outcomes of nonconsent and opportunities to mitigate delayed diagnosis risk

David R Vinson; Madeline J Somers; Edward Qiao; Aidan R Campbell; Grace V Heringer; Cole J Florio; Lara Zekar; Cydney E Middleton; Sara T Woldemariam; Nachiketa Gupta; Luke S Poth; Mary E Reed; Nareg H Roubinian; Ali S Raja; Jeffrey D Sperling

doi:10.1111/acem.15045

Consent to advanced imaging in antenatal pulmonary embolism diagnostics: Prevalence, outcomes of nonconsent and opportunities to mitigate delayed diagnosis risk

Acad Emerg Med. 2024 Nov 17. doi: 10.1111/acem.15045. Online ahead of print.

Authors

David R Vinson^{1

2

3}, Madeline J Somers², Edward Qiao⁴, Aidan R Campbell⁵, Grace V Heringer⁶, Cole J Florio⁷, Lara Zekar⁸, Cydney E Middleton⁸, Sara T Woldemariam⁹, Nachiketa Gupta^{1

10}, Luke S Poth^{1

11}, Mary E Reed², Nareg H Roubinian^{1

2

12}, Ali S Raja¹³, Jeffrey D Sperling^{1

14}

Affiliations

¹ The Permanente Medical Group, Pleasanton, California, USA.
² Kaiser Permanente Northern California Division of Research, Pleasanton, California, USA.
³ Department of Emergency Medicine, Kaiser Permanente Roseville Medical Center, Roseville, California, USA.
⁴ California Northstate University College of Medicine, Elk Grove, California, USA.
⁵ Department of Biology, New York University, New York, New York, USA.
⁶ Department of Neurobiology, Physiology and Behavior, University of California, Davis, California, USA.
⁷ Department of Microbiology and Molecular Genetics, University of California, Davis, California, USA.
⁸ Department of Emergency Medicine, UC Davis Health, Sacramento, California, USA.
⁹ Department of Obstetrics and Gynecology, Kaiser Permanente Oakland Medical Center, Oakland, California, USA.
¹⁰ Department of Emergency Medicine, Kaiser Permanente Redwood City Medical Center, Redwood City, California, USA.
¹¹ Department of Emergency Medicine, Kaiser Permanente South San Francisco Medical Center, San Francisco, California, USA.
¹² Department of Pulmonary and Critical Care Medicine, Kaiser Permanente Oakland Medical Center, Oakland, California, USA.
¹³ Departments of Emergency Medicine and Radiology, Harvard Medical School, Cambridge, Massachusetts, USA.
¹⁴ Department of Maternal and Fetal Medicine, Kaiser Permanente Modesto Medical Center, Modesto, California, USA.

PMID: 39552252
DOI: 10.1111/acem.15045

Abstract

Background: Nonconsent to pulmonary vascular (or advanced) imaging for suspected pulmonary embolism (PE) in pregnancy can delay diagnosis and treatment, increasing risk of adverse outcomes. We sought to understand factors associated with consent and understand outcomes after nonconsent.

Methods: This retrospective cohort study was undertaken across 21 community hospitals from October 1, 2021, through March 31, 2023. We included gravid patients undergoing diagnostics for suspected PE who were recommended advanced imaging. The primary outcome was verbal consent to advanced imaging. Diagnostic settings were nonobstetric (99% emergency departments [EDs]) and obstetrics (labor and delivery and outpatient clinics). Using quasi-Poisson regression, we calculated adjusted relative risks (aRRs) of consenting with 95% confidence intervals (CIs). We also reported symptom resolution and delayed imaging at follow-up and 90-day PE outcomes.

Results: Imaging was recommended for 405 outpatients: median age was 30.5 years; 50% were in the third trimester. Evaluation was more common in nonobstetric (83%) than obstetric settings (17%). Overall, 314 (78%) agreed to imaging and 91 (22%) declined imaging. Consenting was more prevalent in obstetric settings compared with nonobstetric settings: 99% versus 73% (p < 0.001). When adjusted for demographic and clinical variables, including pretest probability, only obstetric setting was independently associated with consenting: aRR 1.26 (95% CI 1.09-1.44). Seventy-nine (87%) patients declining imaging had 30-day follow-up. Eight of 12 who reported persistent or worsening symptoms on follow-up were again recommended advanced imaging and consented. Imaging was negative. None who initially declined imaging were diagnosed with PE or died within 90 days.

Conclusions: One in five gravid patients suspected of PE declined advanced imaging, more commonly in nonobstetric (principally ED) settings than obstetric settings. Patients symptomatic on follow-up responded favorably to subsequent imaging recommendations without 90-day outcomes. Improving the communication and documentation of informed consent and securing close follow-up for nonconsenters may mitigate risks of missed and delayed PE diagnosis.

Abstract

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