The diagnosis of deep vein thrombosis in symptomatic outpatients and the potential for clinical assessment and D‐dimer assays to reduce the need for diagnostic imaging

Keeling, David; Mackie, Ian; Moody, Alan R.; Watson, Henry G.

doi:10.1046/j.1365-2141.2003.04723.x

Cited by 95 publications

(69 citation statements)

References 60 publications

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“…Some have proposed the duration of symptoms cut-off point to be between 7 and 15 days [8,9]. The British Committee for Standards in Haematology recommended that D-dimer testing should be used with caution if the patient had symptoms for over 2 weeks [6].Recently, we retrospectively evaluated the role of D-dimer in a non-invasive clinical approach to VTE. The D-dimer used was a rapid quantitative ELISA method (VIDAS D-dimer; BioMerieux, Marcy l'Etoile, France) with a cut-off level of 500 ng mL )1…”

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confidence: 99%

“…Age of the clot, estimated by the duration of symptoms, is recognized as one of the potential clinical factors affecting the performance of Ddimer, but its cut-off limit has not been accurately defined [6]. In previous studies employing D-dimer, the cut-off point has ranged from 3 days to up to 43 days [6,7]. Some have proposed the duration of symptoms cut-off point to be between 7 and 15 days [8,9].…”

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confidence: 99%

“…To address this problem, many non-invasive management strategies have been proposed to achieve a rapid, safe and costeffective diagnosis. Due to different VTE prevalence, D-dimer performance, and resources available, local validation of these strategies is recommended [6].Despite a few shortcomings, such as method variation, ageand setting-related sensitivity problems and a rather low specificity, D-dimer testing has been successfully employed to rule out VTE in low-risk outpatients [1,2]. Age of the clot, estimated by the duration of symptoms, is recognized as one of the potential clinical factors affecting the performance of Ddimer, but its cut-off limit has not been accurately defined [6].…”

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confidence: 99%

“…Due to different VTE prevalence, D-dimer performance, and resources available, local validation of these strategies is recommended [6].…”

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confidence: 99%

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confidence: 99%

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Duration of symptoms and D‐dimer testing in the ruling‐out of venous thromboembolism

Bastos

Bogutchi

et al. 2006

Journal of Thrombosis and Haemostasis

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Within the last decade, the diagnosis of venous thromboembolism (VTE) has evolved with standard clinical riskstratification models, D-dimer testing and helical computed pulmonary tomography, among others [1][2][3][4][5]. The demand for diagnostic image testing in patients with suspected VTE has increased along with the costs related to this approach. To address this problem, many non-invasive management strategies have been proposed to achieve a rapid, safe and costeffective diagnosis. Due to different VTE prevalence, D-dimer performance, and resources available, local validation of these strategies is recommended [6].Despite a few shortcomings, such as method variation, ageand setting-related sensitivity problems and a rather low specificity, D-dimer testing has been successfully employed to rule out VTE in low-risk outpatients [1,2]. Age of the clot, estimated by the duration of symptoms, is recognized as one of the potential clinical factors affecting the performance of Ddimer, but its cut-off limit has not been accurately defined [6]. In previous studies employing D-dimer, the cut-off point has ranged from 3 days to up to 43 days [6,7]. Some have proposed the duration of symptoms cut-off point to be between 7 and 15 days [8,9]. The British Committee for Standards in Haematology recommended that D-dimer testing should be used with caution if the patient had symptoms for over 2 weeks [6].Recently, we retrospectively evaluated the role of D-dimer in a non-invasive clinical approach to VTE. The D-dimer used was a rapid quantitative ELISA method (VIDAS D-dimer; BioMerieux, Marcy l'Etoile, France) with a cut-off level of 500 ng mL )1. Blood samples were collected prior to anticoagulant treatment. All measurements were carried out by an operator unaware of the results of imaging tests. Imprecision of replicate determinations of samples with D-dimer concentration of 550 ng mL )1 was 5.8%, similar to previous studies that employed this method [8,10].We were able to review the medical records from 335 adults admitted to an outpatient emergency clinic at a hospital located in Belo Horizonte, Brazil, between August 2002 and August 2004. We also reviewed the medical records of these patients during a follow-up period of 90 days. In 205 out of 335 patients (61%) a telephone interview was also successfully undertaken. Deep vein thrombosis (DVT) and pulmonary embolism (PE) were objectively confirmed by compression ultrasonography (CUS) and lung scan or helical chest computed tomography, respectively, following standard criteria [3][4][5]. A patient was considered as having a VTE event when suggestive symptoms associated with positive imaging test were present at a first examination or during the 90-day follow-up period. Therefore, a false-negative case would represent a confirmed VTE event in a patient with a negative D-dimer, and a false-positive case would result from a non-confirmed VTE event in a patient with a positive D-dimer.Population age was 64 ± 14.5 years (range 22-94 years). Male to female ratio was 0.35. The pr...

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confidence: 99%

mentioning

confidence: 99%

mentioning

confidence: 99%

“…Due to different VTE prevalence, D-dimer performance, and resources available, local validation of these strategies is recommended [6].…”

mentioning

confidence: 99%

mentioning

confidence: 99%

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Duration of symptoms and D‐dimer testing in the ruling‐out of venous thromboembolism

Bastos

Bogutchi

et al. 2006

Journal of Thrombosis and Haemostasis

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Cost‐minimization analysis of venous thromboembolism diagnosis: Comparison of standalone imaging with a strategy incorporating D‐dimer for exclusion of venous thromboembolism

Verma

Legnani

Palareti

2017

Research and Practice in Thrombosis and Haemostasis

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Summary Essentials A venous thromboembolism (VTE) diagnostic strategy is economical compared to imaging alone.Applied a VTE diagnostic strategy to a D‐dimer multicenter study for cost‐minimization analysis.Average diagnostic test costs for patients were significantly lower with a diagnostic strategy.Implementation of a VTE diagnostic strategy reduces the diagnostic costs for a hospital. BackgroundThe burden of healthcare costs has substantially risen in the last few decades. One possible contributing factor to this increase are the diagnostic approaches for venous thromboembolism (VTE) using only imaging to exclude a diagnosis of VTE.ObjectiveTo demonstrate cost minimization in the diagnosis of VTE by comparing standalone imaging (computed tomography pulmonary angiography and compression ultrasonography) to a published VTE diagnostic strategy incorporating assessment of pre‐test probability and D‐dimer testing.MethodsWe retrospectively reviewed data from a multicenter diagnostic accuracy study of a D‐dimer reagent where consecutive outpatients (n=747) with suspected VTE, including both pulmonary embolism (n=346) and deep venous thrombosis (n=401) were evaluated. By applying a VTE diagnostic strategy and using the proportion of patients that were diagnosed as VTE‐negative (n=137 for PE; n=120 for DVT), we developed a cost calculator to compare the average diagnostic test cost per suspected VTE patient, both before and after the implementation of the VTE diagnostic strategy.ResultsImplementation of the VTE diagnostic strategy reduced the average diagnostic test cost for a suspected PE patient by 38% and for a suspected DVT patient by 24%. Assuming the proportion of VTE suspected patients to be 30% PE and 70% DVT, the weighted average reduction in the diagnostic test cost per suspected VTE patient was 32%.ConclusionImplementation of a VTE diagnostic strategy can allow hospitals to reduce costs without compromising patient safety.

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D-Dimer Testing: Laboratory Aspects and Current Issues

Thachil

Lippi

Favaloro

2017

Methods in Molecular Biology

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D-dimer has become one of the commonly requested coagulation tests, especially in the venous thromboembolism rule out setting. Appropriate D-dimer testing has significantly decreased the number of radiological investigations in this clinical scenario. D-dimer testing also plays an important role in the diagnostic process of the systemic coagulation disorders, especially disseminated intravascular coagulation in conjunction with other coagulation tests. However, widespread D-dimer testing without good understanding of the technical issues related to the test has recently caused some concerns. This review aims to address the basic physiology of D-dimer formation, the different methods available for its routine assessment, the current problems that both clinicians and laboratory scientists face with this test, and the important need for harmonization of commercial immunoassays.

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The diagnosis of deep vein thrombosis in symptomatic outpatients and the potential for clinical assessment and D‐dimer assays to reduce the need for diagnostic imaging

Cited by 95 publications

References 60 publications

Duration of symptoms and D‐dimer testing in the ruling‐out of venous thromboembolism

Duration of symptoms and D‐dimer testing in the ruling‐out of venous thromboembolism

Cost‐minimization analysis of venous thromboembolism diagnosis: Comparison of standalone imaging with a strategy incorporating D‐dimer for exclusion of venous thromboembolism

D-Dimer Testing: Laboratory Aspects and Current Issues

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