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Ruling Out Pulmonary Embolism in Primary Care: Comparison of the Diagnostic Performance of "Gestalt" and the Wells Rule.
Ann Fam Med. 2016 05; 14(3):227-34.AF

Abstract

PURPOSE

Diagnostic prediction models such as the Wells rule can be used for safely ruling out pulmonary embolism (PE) when it is suspected. A physician's own probability estimate ("gestalt"), however, is commonly used instead. We evaluated the diagnostic performance of both approaches in primary care.

METHODS

Family physicians estimated the probability of PE on a scale of 0% to 100% (gestalt) and calculated the Wells rule score in 598 patients with suspected PE who were thereafter referred to secondary care for definitive testing. We compared the discriminative ability (c statistic) of both approaches. Next, we stratified patients into PE risk categories. For gestalt, a probability of less than 20% plus a negative point-of-care d-dimer test indicated low risk; for the Wells rule, we used a score of 4 or lower plus a negative d-dimer test. We compared sensitivity, specificity, efficiency (percentage of low-risk patients in total cohort), and failure rate (percentage of patients having PE within the low-risk category).

RESULTS

With 3 months of follow-up, 73 patients (12%) were confirmed to have venous thromboembolism (a surrogate for PE at baseline). The c statistic was 0.77 (95% CI, 0.70-0.83) for gestalt and 0.80 (95% CI, 0.75-0.86) for the Wells rule. Gestalt missed 2 out of 152 low-risk patients (failure rate = 1.3%; 95% CI, 0.2%-4.7%) with an efficiency of 25% (95% CI, 22%-29%); the Wells rule missed 4 out of 272 low-risk patients (failure rate = 1.5%; 95% CI, 0.4%-3.7%) with an efficiency of 45% (95% CI, 41%-50%).

CONCLUSIONS

Combined with d-dimer testing, both gestalt using a cutoff of less than 20% and the Wells rule using a score of 4 or lower are safe for ruling out PE in primary care. The Wells rule is more efficient, however, and PE can be ruled out in a larger proportion of suspected cases.

Authors+Show Affiliations

Department of Epidemiology, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, The Netherlands j.m.t.hendriksen-9@umcutrecht.nl.Department of General Practice, Academic Medical Center, Amsterdam, The Netherlands.Department of Family Medicine, CAPHRI School for Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands.Department of Family Medicine, CAPHRI School for Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands.Department of General Practice, Academic Medical Center, Amsterdam, The Netherlands.Department of Vascular Medicine, Academic Medical Center, Amsterdam, The Netherlands.Department of Epidemiology, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, The Netherlands.Department of Epidemiology, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, The Netherlands.Department of Epidemiology, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, The Netherlands.

Pub Type(s)

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

Language

eng

PubMed ID

27184993

Citation

Hendriksen, Janneke M T., et al. "Ruling Out Pulmonary Embolism in Primary Care: Comparison of the Diagnostic Performance of "Gestalt" and the Wells Rule." Annals of Family Medicine, vol. 14, no. 3, 2016, pp. 227-34.
Hendriksen JM, Lucassen WA, Erkens PM, et al. Ruling Out Pulmonary Embolism in Primary Care: Comparison of the Diagnostic Performance of "Gestalt" and the Wells Rule. Ann Fam Med. 2016;14(3):227-34.
Hendriksen, J. M., Lucassen, W. A., Erkens, P. M., Stoffers, H. E., van Weert, H. C., Büller, H. R., Hoes, A. W., Moons, K. G., & Geersing, G. J. (2016). Ruling Out Pulmonary Embolism in Primary Care: Comparison of the Diagnostic Performance of "Gestalt" and the Wells Rule. Annals of Family Medicine, 14(3), 227-34. https://doi.org/10.1370/afm.1930
Hendriksen JM, et al. Ruling Out Pulmonary Embolism in Primary Care: Comparison of the Diagnostic Performance of "Gestalt" and the Wells Rule. Ann Fam Med. 2016;14(3):227-34. PubMed PMID: 27184993.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Ruling Out Pulmonary Embolism in Primary Care: Comparison of the Diagnostic Performance of "Gestalt" and the Wells Rule. AU - Hendriksen,Janneke M T, AU - Lucassen,Wim A M, AU - Erkens,Petra M G, AU - Stoffers,Henri E J H, AU - van Weert,Henk C P M, AU - Büller,Harry R, AU - Hoes,Arno W, AU - Moons,Karel G M, AU - Geersing,Geert-Jan, PY - 2015/07/31/received PY - 2016/01/20/accepted PY - 2016/5/18/entrez PY - 2016/5/18/pubmed PY - 2017/11/1/medline KW - deep venous thrombosis KW - diagnostic prediction models KW - family practice KW - gestalt KW - practice-based research KW - primary care KW - pulmonary embolism SP - 227 EP - 34 JF - Annals of family medicine JO - Ann Fam Med VL - 14 IS - 3 N2 - PURPOSE: Diagnostic prediction models such as the Wells rule can be used for safely ruling out pulmonary embolism (PE) when it is suspected. A physician's own probability estimate ("gestalt"), however, is commonly used instead. We evaluated the diagnostic performance of both approaches in primary care. METHODS: Family physicians estimated the probability of PE on a scale of 0% to 100% (gestalt) and calculated the Wells rule score in 598 patients with suspected PE who were thereafter referred to secondary care for definitive testing. We compared the discriminative ability (c statistic) of both approaches. Next, we stratified patients into PE risk categories. For gestalt, a probability of less than 20% plus a negative point-of-care d-dimer test indicated low risk; for the Wells rule, we used a score of 4 or lower plus a negative d-dimer test. We compared sensitivity, specificity, efficiency (percentage of low-risk patients in total cohort), and failure rate (percentage of patients having PE within the low-risk category). RESULTS: With 3 months of follow-up, 73 patients (12%) were confirmed to have venous thromboembolism (a surrogate for PE at baseline). The c statistic was 0.77 (95% CI, 0.70-0.83) for gestalt and 0.80 (95% CI, 0.75-0.86) for the Wells rule. Gestalt missed 2 out of 152 low-risk patients (failure rate = 1.3%; 95% CI, 0.2%-4.7%) with an efficiency of 25% (95% CI, 22%-29%); the Wells rule missed 4 out of 272 low-risk patients (failure rate = 1.5%; 95% CI, 0.4%-3.7%) with an efficiency of 45% (95% CI, 41%-50%). CONCLUSIONS: Combined with d-dimer testing, both gestalt using a cutoff of less than 20% and the Wells rule using a score of 4 or lower are safe for ruling out PE in primary care. The Wells rule is more efficient, however, and PE can be ruled out in a larger proportion of suspected cases. SN - 1544-1717 UR - https://www.unboundmedicine.com/medline/citation/27184993/Ruling_Out_Pulmonary_Embolism_in_Primary_Care:_Comparison_of_the_Diagnostic_Performance_of_"Gestalt"_and_the_Wells_Rule_ L2 - http://www.annfammed.org/cgi/pmidlookup?view=long&pmid=27184993 DB - PRIME DP - Unbound Medicine ER -