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Safe exclusion of pulmonary embolism using the Wells rule and qualitative D-dimer testing in primary care: prospective cohort study.
BMJ. 2012 Oct 04; 345:e6564.BMJ

Abstract

OBJECTIVE

To validate the use of the Wells clinical decision rule combined with a point of care D-dimer test to safely exclude pulmonary embolism in primary care.

DESIGN

Prospective cohort study.

SETTING

Primary care across three different regions of the Netherlands (Amsterdam, Maastricht, and Utrecht).

PARTICIPANTS

598 adults with suspected pulmonary embolism in primary care.

INTERVENTIONS

Doctors scored patients according to the seven variables of the Wells rule and carried out a qualitative point of care D-dimer test. All patients were referred to secondary care and diagnosed according to local protocols. Pulmonary embolism was confirmed or refuted on the basis of a composite reference standard, including spiral computed tomography and three months' follow-up.

MAIN OUTCOME MEASURES

Diagnostic accuracy (sensitivity and specificity), proportion of patients at low risk (efficiency), number of missed patients with pulmonary embolism in low risk category (false negative rate), and the presence of symptomatic venous thromboembolism, based on the composite reference standard, including events during the follow-up period of three months.

RESULTS

Pulmonary embolism was present in 73 patients (prevalence 12.2%). On the basis of a threshold Wells score of ≤ 4 and a negative qualitative D-dimer test result, 272 of 598 patients were classified as low risk (efficiency 45.5%). Four cases of pulmonary embolism were observed in these 272 patients (false negative rate 1.5%, 95% confidence interval 0.4% to 3.7%). The sensitivity and specificity of this combined diagnostic approach was 94.5% (86.6% to 98.5%) and 51.0% (46.7% to 55.4%), respectively.

CONCLUSION

A Wells score of ≤ 4 combined with a negative qualitative D-dimer test result can safely and efficiently exclude pulmonary embolism in primary care.

Authors+Show Affiliations

Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Universiteitsweg 100, 3584 CG Utrecht, Netherlands. g.j.geersing@umcutrecht.nlNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info available

Pub Type(s)

Journal Article
Research Support, Non-U.S. Gov't
Validation Study

Language

eng

PubMed ID

23036917

Citation

Geersing, Geert-Jan, et al. "Safe Exclusion of Pulmonary Embolism Using the Wells Rule and Qualitative D-dimer Testing in Primary Care: Prospective Cohort Study." BMJ (Clinical Research Ed.), vol. 345, 2012, pp. e6564.
Geersing GJ, Erkens PM, Lucassen WA, et al. Safe exclusion of pulmonary embolism using the Wells rule and qualitative D-dimer testing in primary care: prospective cohort study. BMJ. 2012;345:e6564.
Geersing, G. J., Erkens, P. M., Lucassen, W. A., Büller, H. R., Cate, H. T., Hoes, A. W., Moons, K. G., Prins, M. H., Oudega, R., van Weert, H. C., & Stoffers, H. E. (2012). Safe exclusion of pulmonary embolism using the Wells rule and qualitative D-dimer testing in primary care: prospective cohort study. BMJ (Clinical Research Ed.), 345, e6564. https://doi.org/10.1136/bmj.e6564
Geersing GJ, et al. Safe Exclusion of Pulmonary Embolism Using the Wells Rule and Qualitative D-dimer Testing in Primary Care: Prospective Cohort Study. BMJ. 2012 Oct 4;345:e6564. PubMed PMID: 23036917.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Safe exclusion of pulmonary embolism using the Wells rule and qualitative D-dimer testing in primary care: prospective cohort study. AU - Geersing,Geert-Jan, AU - Erkens,Petra M G, AU - Lucassen,Wim A M, AU - Büller,Harry R, AU - Cate,Hugo Ten, AU - Hoes,Arno W, AU - Moons,Karel G M, AU - Prins,Martin H, AU - Oudega,Ruud, AU - van Weert,Henk C P M, AU - Stoffers,Henri E J H, Y1 - 2012/10/04/ PY - 2012/10/6/entrez PY - 2012/10/6/pubmed PY - 2012/12/10/medline SP - e6564 EP - e6564 JF - BMJ (Clinical research ed.) JO - BMJ VL - 345 N2 - OBJECTIVE: To validate the use of the Wells clinical decision rule combined with a point of care D-dimer test to safely exclude pulmonary embolism in primary care. DESIGN: Prospective cohort study. SETTING: Primary care across three different regions of the Netherlands (Amsterdam, Maastricht, and Utrecht). PARTICIPANTS: 598 adults with suspected pulmonary embolism in primary care. INTERVENTIONS: Doctors scored patients according to the seven variables of the Wells rule and carried out a qualitative point of care D-dimer test. All patients were referred to secondary care and diagnosed according to local protocols. Pulmonary embolism was confirmed or refuted on the basis of a composite reference standard, including spiral computed tomography and three months' follow-up. MAIN OUTCOME MEASURES: Diagnostic accuracy (sensitivity and specificity), proportion of patients at low risk (efficiency), number of missed patients with pulmonary embolism in low risk category (false negative rate), and the presence of symptomatic venous thromboembolism, based on the composite reference standard, including events during the follow-up period of three months. RESULTS: Pulmonary embolism was present in 73 patients (prevalence 12.2%). On the basis of a threshold Wells score of ≤ 4 and a negative qualitative D-dimer test result, 272 of 598 patients were classified as low risk (efficiency 45.5%). Four cases of pulmonary embolism were observed in these 272 patients (false negative rate 1.5%, 95% confidence interval 0.4% to 3.7%). The sensitivity and specificity of this combined diagnostic approach was 94.5% (86.6% to 98.5%) and 51.0% (46.7% to 55.4%), respectively. CONCLUSION: A Wells score of ≤ 4 combined with a negative qualitative D-dimer test result can safely and efficiently exclude pulmonary embolism in primary care. SN - 1756-1833 UR - https://www.unboundmedicine.com/medline/citation/23036917/Safe_exclusion_of_pulmonary_embolism_using_the_Wells_rule_and_qualitative_D_dimer_testing_in_primary_care:_prospective_cohort_study_ L2 - https://www.bmj.com/lookup/pmidlookup?view=long&pmid=23036917 DB - PRIME DP - Unbound Medicine ER -