RT Journal
A1 Venkatesh A, Kline JA, Kabrhel C
T1 COmputed tomography in the emergency department setting—reply
JF JAMA Internal Medicine
JO JAMA Internal Medicine
YR 2013
FD January 28
VO 173
IS 2
SP 167
OP 168
DO 10.1001/jamainternmed.2013.1548
UL http://dx.doi.org/10.1001/jamainternmed.2013.1548
AB 
We recently reported that approximately one-third of all imaging studies for pulmonary embolism (PE) are potentially avoidable based on a National Quality Forum endorsed performance measure.1 Inherent in the construction of any performance measure is the assumption that the care of patients can be simplified into necessary/avoidable, appropriate/inappropriate, good/bad. This simplification is readily apparent when we attempt to measure quality in the diagnosis of undifferentiated patients with potentially dangerous, nonspecific complaints. Dr Goodman is correct when he says that patients present for “signs/symptoms needing a rapid explanation,” rather than a “PE diagnosis.” However, we disagree with his tacit conclusion that any attempt to measure imaging appropriateness in complex patients is therefore futile. Rather than concluding that quality can only be measured at the level of an individual patient, we believe that results such as ours should be used to balance the potentially endless pursuit of diagnostic certainty against the risk that overtesting poses to our patients and the health care system.