Clinical pre‐test probability adjusted versus age‐adjusted D‐dimer interpretation strategy for DVT diagnosis: A diagnostic individual patient data meta‐analysis

Parpia, Sameer; Lapner, Sarah Takach; Schutgens, Roger E. G.; Elf, Johan; Geersing, Geert Jan; Kearon, Clive

doi:10.1111/jth.14718

Cited by 20 publications

(20 citation statements)

References 27 publications

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“…Although we did not conduct a formal comparison between the strategies, obtaining the Wells score at inclusion enabled us to retrospectively assess the diagnostic properties of strategies including the Wells score in the diagnostic algorithm ( Recent attempts to increase specificity and reduce the number of unnecessary CUS examinations include increasing thresholds for positive D-dimer in older patients or in patients with low C-PTP. 34 In our study, both strategies would have required CUS in 66% of patients because of positive D-dimer or high C-PTP, 4% less than our strategy albeit at the cost of a slightly higher failure rate (Table 2).…”

Section: Principal Findingsmentioning

confidence: 60%

“…To our knowledge, comparisons between alternative D-dimer thresholds, such as stand-alone, age-adjusted, and C-PTP-adjusted D-dimer, have been retrospective. 6,11,34 For future research, a prospective multicenter study with a head-to-head comparison of the various strategies would be useful in determining the optimal strategy. Future research efforts aimed at obviating unnecessary diagnostic workup altogether would further advance the management of patients with suspected DVT, for instance, by identifying new biomarkers and/or developing machine-learning strategies.…”

Section: Strengths Limitations and Clinical Implicationsmentioning

confidence: 99%

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Safety of a strategy combining D-dimer testing and whole-leg ultrasonography to rule out deep vein thrombosis

et al. 2020

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Guidelines for the diagnostic workup of deep vein thrombosis (DVT) recommend assessing the clinical pretest probability before proceeding to D-dimer testing and/or compression ultrasonography (CUS) if the patient has high pretest probability or positive D-dimer. Referring only patients with positive D-dimer for whole-leg CUS irrespective of pretest probability may simplify the workup of DVT. In this prospective management outcome study, we assessed the safety of such a strategy. We included consecutive outpatients referred to the Emergency Department at Østfold Hospital, Norway, with suspected DVT between February 2015 and November 2018. STA-Liatest D-Di Plus D-dimer was analyzed for all patients, and only patients with levels ≥0.5 µg/mL were referred for CUS. All patients with negative D-dimer or negative CUS were followed for 3 months to assess the venous thromboembolic rate. One thousand three hundred ninety-seven patients were included. Median age was 64 years (interquartile range, 52-73 years), and 770 patients (55%) were female. D-dimer was negative in 415 patients (29.7%) and positive in 982 patients (70.3%). DVT was diagnosed in 277 patients (19.8%). Six patients in whom DVT was ruled out at baseline were diagnosed with DVT within 3 months of follow-up for a thromboembolic rate of 0.5% (95% confidence interval, 0.2-1.2). A simple diagnostic approach with initial stand-alone D-dimer followed by a single whole-leg CUS in patients with positive D-dimer safely ruled out DVT. We consider this strategy to be a valuable alternative to the conventional workup of DVT in outpatients. This trial was registered at www.clinicaltrials.gov as #NCT02486445.

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Section: Principal Findingsmentioning

confidence: 60%

Section: Strengths Limitations and Clinical Implicationsmentioning

confidence: 99%

Safety of a strategy combining D-dimer testing and whole-leg ultrasonography to rule out deep vein thrombosis

et al. 2020

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“…We found our new rule excluded DVT in a similar proportion of patients as the Wells Score CPTP‐adjusted D‐dimer strategy 23 ; however, there are several compelling reasons why this new rule might have a greater clinical utility. First, the Wells score has nine items, some of which consist of multiple components.…”

Section: Discussionmentioning

confidence: 78%

A simplified decision rule to rule out deep vein thrombosis using clinical assessment and D‐dimer

Wit

Geersing

et al. 2021

Journal of Thrombosis and Haemostasis

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Background Current clinical decision rules to exclude deep vein thrombosis (DVT) are underused partly because of their complexity. A simplified rule that can be easily applied would be more appealing to use in clinical practice. Methods We used individual patient data from prospective diagnostic studies of patients suspected of DVT to develop a new clinical decision rule. The primary outcome was presence of DVT either at initial testing or during follow‐up. DVT was considered safely excluded if the upper 95% confidence interval (CI) of DVT prevalence was <2%. Results Four studies and 3368 patients were eligible for this analysis. Overall prevalence of DVT was 17%. In addition to D‐dimer, two variables, calf swelling and DVT as the most likely diagnosis, are included in the new rule. Based on these two variables, two clinical pretest probability (CPTP) groups were defined; low (none of the two items present) and high (at least one of the items present). DVT can be safely excluded in patients with low CPTP with a D‐dimer <500 ng/mL (prevalence = 0.1%; 95% CI, 0.0‐0.8), low CPTP with a D‐dimer between 500 ng/ml and 1000 ng/ml (prevalence = 0.3%; 95% CI, 0.0‐1.7), and D‐dimer <500 ng/ml in patients with high CPTP (prevalence = 0.3%; 95% CI, 0.0‐1.0). Conclusions The combination of D‐dimer and Wells items resulted in a simple clinical decision rule with 3 items. The results suggest that the rule can safely exclude DVT. Prospective validation is required.

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“…Usually, some widely accepted diagnostic approaches of DVT include the judgment based on doctors’ clinical suspicion, the use of Wells score for risk stratification and the D-dimer in low-risk patients, to reduce unnecessary imaging. 20 , 21 The current practice is that patients are screened by compression ultrasound for the first time within the first week of admission to NICU. However, regardless of the results, patients must receive compression ultrasound every week until they leave the hospital.…”

Section: Predictive Analysesmentioning

confidence: 99%

Cost-Effective Machine Learning Based Clinical Pre-Test Probability Strategy for DVT Diagnosis in Neurological Intensive Care Unit

Luo

Kou

Feng

et al. 2021

Clin Appl Thromb Hemost

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In order to overcome the shortage of the current costly DVT diagnosis and reduce the waste of valuable healthcare resources, we proposed a new diagnostic approach based on machine learning pre-test prediction models using EHRs. We examined the sociodemographic and clinical factors in the prediction of DVT with 518 NICU admitted patients, including 189 patients who eventually developed DVT. We used cross-validation on the training data to determine the optimal parameters, and finally, the applied ROC analysis is adopted to evaluate the predictive strength of each model. Two models (GLM and SVM) with the strongest ROC were selected for DVT prediction, based on which, we optimized the current intervention and diagnostic process of DVT and examined the performance of the proposed approach through simulations. The use of machine learning based pre-test prediction models can simplify and improve the intervention and diagnostic process of patients in NICU with suspected DVT, and reduce the valuable healthcare resource occupation/usage and medical costs.

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Clinical pre‐test probability adjusted versus age‐adjusted D‐dimer interpretation strategy for DVT diagnosis: A diagnostic individual patient data meta‐analysis

Cited by 20 publications

References 27 publications

Safety of a strategy combining D-dimer testing and whole-leg ultrasonography to rule out deep vein thrombosis

Safety of a strategy combining D-dimer testing and whole-leg ultrasonography to rule out deep vein thrombosis

A simplified decision rule to rule out deep vein thrombosis using clinical assessment and D‐dimer

Cost-Effective Machine Learning Based Clinical Pre-Test Probability Strategy for DVT Diagnosis in Neurological Intensive Care Unit

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