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Accuracy of the Wells clinical prediction rule for pulmonary embolism in older ambulatory adults.
J Am Geriatr Soc. 2014 Nov; 62(11):2136-41.JA

Abstract

OBJECTIVES

To determine whether the Wells clinical prediction rule for pulmonary embolism (PE), which produces a point score based on clinical features and the likelihood of diagnoses other than PE, combined with normal D-dimer testing can be used to exclude PE in older unhospitalized adults.

DESIGN

Prospective cohort study.

SETTING

Primary care and nursing homes.

PARTICIPANTS

Older adults (≥60) clinically suspected of having a PE (N = 294, mean age 76, 44% residing in a nursing home).

MEASUREMENTS

The presence of PE was confirmed using a composite reference standard including computed tomography and 3-month follow-up. The proportion of individuals with an unlikely risk of PE was calculated according to the Wells rule (≤4 points) plus a normal qualitative point-of-care D-dimer test (efficiency) and the presence of symptomatic PE during 3 months of follow-up within these patients (failure rate).

RESULTS

Pulmonary embolism occurred in 83 participants (28%). Eighty-five participants had an unlikely risk according to the Wells rule and a normal D-dimer test (efficiency 29%), five of whom experienced a nonfatal PE during 3 months of follow-up (failure rate = 5.9%, 95% confidence interval (CI) = 2.5-13%). According to a refitted diagnostic strategy for older adults, 69 had a low risk of PE (24%), two of whom had PE (failure rate = 2.9%, 95% CI = 0.8-10%).

CONCLUSION

The use of the well-known and widely used Wells rule (original or refitted) does not guarantee safe exclusion of PE in older unhospitalized adults with suspected PE. This may lead to discussion among professionals as to whether the original or revised Wells rule is useful for elderly outpatients.

Authors+Show Affiliations

Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands; Department of Geriatrics, University Medical Center Utrecht, Utrecht, the Netherlands.No affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info available

Pub Type(s)

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

Language

eng

PubMed ID

25366538

Citation

Schouten, Henrike J., et al. "Accuracy of the Wells Clinical Prediction Rule for Pulmonary Embolism in Older Ambulatory Adults." Journal of the American Geriatrics Society, vol. 62, no. 11, 2014, pp. 2136-41.
Schouten HJ, Geersing GJ, Oudega R, et al. Accuracy of the Wells clinical prediction rule for pulmonary embolism in older ambulatory adults. J Am Geriatr Soc. 2014;62(11):2136-41.
Schouten, H. J., Geersing, G. J., Oudega, R., van Delden, J. J., Moons, K. G., & Koek, H. L. (2014). Accuracy of the Wells clinical prediction rule for pulmonary embolism in older ambulatory adults. Journal of the American Geriatrics Society, 62(11), 2136-41. https://doi.org/10.1111/jgs.13080
Schouten HJ, et al. Accuracy of the Wells Clinical Prediction Rule for Pulmonary Embolism in Older Ambulatory Adults. J Am Geriatr Soc. 2014;62(11):2136-41. PubMed PMID: 25366538.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Accuracy of the Wells clinical prediction rule for pulmonary embolism in older ambulatory adults. AU - Schouten,Henrike J, AU - Geersing,Geert-Jan, AU - Oudega,Ruud, AU - van Delden,Johannes J M, AU - Moons,Karel G M, AU - Koek,Huiberdina L, Y1 - 2014/11/03/ PY - 2014/11/5/entrez PY - 2014/11/5/pubmed PY - 2015/1/27/medline KW - D-dimer KW - Wells KW - clinical decision rule KW - diagnosis KW - elderly KW - geriatric KW - nursing home KW - pulmonary embolism KW - venous thromboembolism SP - 2136 EP - 41 JF - Journal of the American Geriatrics Society JO - J Am Geriatr Soc VL - 62 IS - 11 N2 - OBJECTIVES: To determine whether the Wells clinical prediction rule for pulmonary embolism (PE), which produces a point score based on clinical features and the likelihood of diagnoses other than PE, combined with normal D-dimer testing can be used to exclude PE in older unhospitalized adults. DESIGN: Prospective cohort study. SETTING: Primary care and nursing homes. PARTICIPANTS: Older adults (≥60) clinically suspected of having a PE (N = 294, mean age 76, 44% residing in a nursing home). MEASUREMENTS: The presence of PE was confirmed using a composite reference standard including computed tomography and 3-month follow-up. The proportion of individuals with an unlikely risk of PE was calculated according to the Wells rule (≤4 points) plus a normal qualitative point-of-care D-dimer test (efficiency) and the presence of symptomatic PE during 3 months of follow-up within these patients (failure rate). RESULTS: Pulmonary embolism occurred in 83 participants (28%). Eighty-five participants had an unlikely risk according to the Wells rule and a normal D-dimer test (efficiency 29%), five of whom experienced a nonfatal PE during 3 months of follow-up (failure rate = 5.9%, 95% confidence interval (CI) = 2.5-13%). According to a refitted diagnostic strategy for older adults, 69 had a low risk of PE (24%), two of whom had PE (failure rate = 2.9%, 95% CI = 0.8-10%). CONCLUSION: The use of the well-known and widely used Wells rule (original or refitted) does not guarantee safe exclusion of PE in older unhospitalized adults with suspected PE. This may lead to discussion among professionals as to whether the original or revised Wells rule is useful for elderly outpatients. SN - 1532-5415 UR - https://www.unboundmedicine.com/medline/citation/25366538/Accuracy_of_the_Wells_clinical_prediction_rule_for_pulmonary_embolism_in_older_ambulatory_adults_ L2 - https://doi.org/10.1111/jgs.13080 DB - PRIME DP - Unbound Medicine ER -