Comparing the diagnostic performance of 2 clinical decision rules to rule out deep vein thrombosis in primary care patients

doi:10.1370/afm.1198

Comparative Study

. 2011 Jan-Feb;9(1):31-6.

doi: 10.1370/afm.1198.

Comparing the diagnostic performance of 2 clinical decision rules to rule out deep vein thrombosis in primary care patients

Eit Frits van der Velde¹, Diane B Toll, Arina J Ten Cate-Hoek, Ruud Oudega, Henri E J H Stoffers, Patrick M Bossuyt, Harry R Büller, Martin H Prins, Arno W Hoes, Karel G M Moons, Henk C P M van Weert

Affiliations

PMID: 21242558
PMCID: PMC3022042
DOI: 10.1370/afm.1198

Comparative Study

Comparing the diagnostic performance of 2 clinical decision rules to rule out deep vein thrombosis in primary care patients

Eit Frits van der Velde et al. Ann Fam Med. 2011 Jan-Feb.

. 2011 Jan-Feb;9(1):31-6.

doi: 10.1370/afm.1198.

Authors

Affiliation

¹ Department of General Practice, Vascular Medicine and Clinical Epidemiology, University of Amsterdam, The Netherlands. e.f.vandervelde@amc.uva.nl

PMID: 21242558
PMCID: PMC3022042
DOI: 10.1370/afm.1198

Abstract

Purpose: The Wells rule is widely used for clinical assessment of patients with suspected deep vein thrombosis (DVT), especially in the secondary care setting. Recently a new clinical decision rule for primary care patients (the primary care rule) has been proposed, because the Wells rule is not sufficient to rule out DVT in this setting. The objective was to compare the ability of both rules to safely rule out DVT and to efficiently reduce the number of referrals for leg ultrasound investigation that would result in a negative finding.

Methods: Family physicians collected data on 1,086 patients to calculate the scores for both decision rules before leg ultrasonography was performed. In all patients D-dimer (dimerized plasmin fragment D) testing was performed using a rapid point-of-care assay. Patients were stratified into risk categories defined by each rule and the D-dimer result. Outcomes were DVT (diagnosed by ultrasonography) and venous thromboembolic complications or death caused by a possible thromboembolic event during a 90-day follow-up period. We calculated the differences between the 2 rules in the number of missed diagnoses and the proportions of patients that needed ultrasound testing.

Results: Data from 1,002 eligible patients were used for this analysis. A venous thromboembolic event occurred during follow-up in 7 patients with a low score and negative D-dimer finding, both with the Wells rule (7 of 447; 1.6%; 95% confidence interval [CI], 0.7%-3.3% ) and the primary care rule (7 of 495; 1.4%; 95% CI, 0.6%-3.0%). Using the Wells rule, 447 patients (45%) would not need referral for further testing compared with 495 patients (49%) when using the primary care rule (McNemar P <.001).

Conclusions: In primary care, suspected DVT can safely be ruled out using either of the 2 rules in combination with a point-of-care D-dimer test. Both rules can reduce unnecessary referrals for compression ultrasonography by about 50%, though the primary care rule reduces it slightly more.

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Comment in

Mit Wells-Score und Primary-Care-Rule können tiefe Venenthrombosen mit grosser Sicherheit ausgeschlossen werden.
Steurer J. Steurer J. Praxis (Bern 1994). 2011 May 11;100(10):619-20. doi: 10.1024/1661-8157/a000536. Praxis (Bern 1994). 2011. PMID: 21563102 German. No abstract available.
ACP Journal Club. The Wells rule and a primary care rule were useful for ruling out deep venous thrombosis in primary care.
Iorio A. Iorio A. Ann Intern Med. 2011 Jun 21;154(12):JC6-13. doi: 10.7326/0003-4819-154-12-201106210-02013. Ann Intern Med. 2011. PMID: 21690591 No abstract available.

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References

1. Huerta C, Johansson S, Wallander MA, García Rodríguez LA. Risk factors and short-term mortality of venous thromboembolism diagnosed in the primary care setting in the United Kingdom. Arch Intern Med. 2007;167(9):935–943. - PubMed
1. Kilroy DA, Ireland S, Reid P, Goodacre S, Morris F. Emergency department investigation of deep vein thrombosis. Emerg Med J. 2003;20(1):29–32. - PMC - PubMed
1. Prandoni P, Lensing AW, Cogo A, et al. The long-term clinical course of acute deep venous thrombosis. Ann Intern Med. 1996;125(1):1–7. - PubMed
1. White RH. The epidemiology of venous thromboembolism. Circulation. 2003;107(23)(Suppl 1):I4–I8. - PubMed
1. Oudega R, Moons KG, Hoes AW. Ruling out deep venous thrombosis in primary care. A simple diagnostic algorithm including D-dimer testing. Thromb Haemost. 2005;94(1):200–205. - PubMed

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[1] Huerta C, Johansson S, Wallander MA, García Rodríguez LA. Risk factors and short-term mortality of venous thromboembolism diagnosed in the primary care setting in the United Kingdom. Arch Intern Med. 2007;167(9):935–943. - PubMed

[2] Huerta C, Johansson S, Wallander MA, García Rodríguez LA. Risk factors and short-term mortality of venous thromboembolism diagnosed in the primary care setting in the United Kingdom. Arch Intern Med. 2007;167(9):935–943. - PubMed

[3] Kilroy DA, Ireland S, Reid P, Goodacre S, Morris F. Emergency department investigation of deep vein thrombosis. Emerg Med J. 2003;20(1):29–32. - PMC - PubMed

[4] Kilroy DA, Ireland S, Reid P, Goodacre S, Morris F. Emergency department investigation of deep vein thrombosis. Emerg Med J. 2003;20(1):29–32. - PMC - PubMed

[5] Prandoni P, Lensing AW, Cogo A, et al. The long-term clinical course of acute deep venous thrombosis. Ann Intern Med. 1996;125(1):1–7. - PubMed

[6] Prandoni P, Lensing AW, Cogo A, et al. The long-term clinical course of acute deep venous thrombosis. Ann Intern Med. 1996;125(1):1–7. - PubMed

[7] White RH. The epidemiology of venous thromboembolism. Circulation. 2003;107(23)(Suppl 1):I4–I8. - PubMed

[8] White RH. The epidemiology of venous thromboembolism. Circulation. 2003;107(23)(Suppl 1):I4–I8. - PubMed

[9] Oudega R, Moons KG, Hoes AW. Ruling out deep venous thrombosis in primary care. A simple diagnostic algorithm including D-dimer testing. Thromb Haemost. 2005;94(1):200–205. - PubMed

[10] Oudega R, Moons KG, Hoes AW. Ruling out deep venous thrombosis in primary care. A simple diagnostic algorithm including D-dimer testing. Thromb Haemost. 2005;94(1):200–205. - PubMed

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Comparing the diagnostic performance of 2 clinical decision rules to rule out deep vein thrombosis in primary care patients

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Comparing the diagnostic performance of 2 clinical decision rules to rule out deep vein thrombosis in primary care patients

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