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1.
J Thromb Haemost ; 2020 May 20.
Artigo em Inglês | MEDLINE | ID: mdl-32433797

RESUMO

BACKGROUND: A previous individual participant data (IPD) meta-analysis showed that the Wells-rule and D-dimer testing cannot exclude suspected deep vein thrombosis (DVT) in cancer patients. OBJECTIVES: To explore reasons for this reduced diagnostic accuracy and to optimize the diagnostic pathway for cancer patients suspected of DVT. PATIENTS AND METHODS: Using IPD from 13 studies in patients with suspected DVT, DVT prevalence and the predictive value of the Wells-rule items and D-dimer testing were compared between patients with and without cancer. Next, we developed a prediction model with five variables selected from all available diagnostic predictors. RESULTS: Among the 10,002 suspected DVT patients, there were 834 patients with cancer. The median prevalence of DVT in these patients with cancer was 37.5% (interquartile range [IQR] 30.8-45.5), while it was 15.1% (IQR 11.5-16.7) in patients without cancer. Diagnostic performance of individual Wells-rule items and D-dimer testing was similar across patients with and without cancer, except 'immobility' and 'history of DVT'. The newly developed rule showed a pooled c-statistic 0.80 (95% confidence interval [CI] 0.75-0.83) and good calibration. However, using this model, still only 4.3% (95% CI 3.0-5.7) of the suspected patients with cancer could be identified with a predicted DVT post-test probability of less than 2%. CONCLUSIONS: Likely due to the high prevalence of DVT, clinical models followed by D-dimer testing fail to rule-out DVT efficiently in cancer patients suspected of DVT. Direct referral for compression ultrasonography appears to be the preferred approach for diagnosis of suspected DVT in cancer patients.

2.
Perm J ; 242020.
Artigo em Inglês | MEDLINE | ID: mdl-32240089

RESUMO

INTRODUCTION: The evidence for outpatient management of hemodynamically stable, low-risk patients with acute symptomatic pulmonary embolism (PE) is mounting. Guidance in identifying patients who are eligible for outpatient (ambulatory) care is available in the literature and society guidelines. Less is known about who can identify patients eligible for outpatient management and in what clinical practice settings. OBJECTIVE: To answer the question, "Can primary care do this?" (provide comprehensive outpatient management of low-risk PE). METHODS: We undertook a narrative review of the literature on the outpatient management of acute PE focusing on site of care. We searched the English-language literature in PubMed and Embase from January 1, 1950, through July 15, 2019. RESULTS: We identified 26 eligible studies. We found no studies that evaluated comprehensive PE management in a primary care clinic or general practice setting. In 19 studies, the site-of-care decision making occurred in the Emergency Department (or after a short period of supplemental observation) and in 7 studies the decision occurred in a specialty clinic. We discuss the components of care involved in the diagnosis, outpatient eligibility assessment, treatment, and follow-up of ambulatory patients with acute PE. DISCUSSION: We see no formal reason why a trained primary care physician could not provide comprehensive care for select patients with low-risk PE. Leading obstacles include lack of ready access to advanced pulmonary imaging and the time constraints of a busy outpatient clinic. CONCLUSION: Until studies establish safe parameters of such a practice, the question "Can primary care do this?" must remain open.

3.
Eur Heart J ; 2020 Feb 29.
Artigo em Inglês | MEDLINE | ID: mdl-32112556

RESUMO

AIMS: To evaluate whether integrated care for atrial fibrillation (AF) can be safely orchestrated in primary care. METHODS AND RESULTS: The ALL-IN trial was a cluster randomized, open-label, pragmatic non-inferiority trial performed in primary care practices in the Netherlands. We randomized 26 practices: 15 to the integrated care intervention and 11 to usual care. The integrated care intervention consisted of (i) quarterly AF check-ups by trained nurses in primary care, also focusing on possibly interfering comorbidities, (ii) monitoring of anticoagulation therapy in primary care, and finally (iii) easy-access availability of consultations from cardiologists and anticoagulation clinics. The primary endpoint was all-cause mortality during 2 years of follow-up. In the intervention arm, 527 out of 941 eligible AF patients aged ≥65 years provided informed consent to undergo the intervention. These 527 patients were compared with 713 AF patients in the control arm receiving usual care. Median age was 77 (interquartile range 72-83) years. The all-cause mortality rate was 3.5 per 100 patient-years in the intervention arm vs. 6.7 per 100 patient-years in the control arm [adjusted hazard ratio (HR) 0.55; 95% confidence interval (CI) 0.37-0.82]. For non-cardiovascular mortality, the adjusted HR was 0.47 (95% CI 0.27-0.82). For other adverse events, no statistically significant differences were observed. CONCLUSION: In this cluster randomized trial, integrated care for elderly AF patients in primary care showed a 45% reduction in all-cause mortality when compared with usual care.

5.
J Thromb Haemost ; 18(3): 669-675, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-31869505

RESUMO

BACKGROUND: To increase the clinical usefulness of the D-dimer test in diagnosis of deep vein thrombosis (DVT), two strategies have been proposed: the age-adjusted, and the clinical pre-test probability (CPTP) adjusted interpretation. However, it is not known which of these strategies is superior. OBJECTIVE: To conduct an individual patient data (IPD) meta-analysis that compares the sensitivity, specificity, negative predictive value (NPV), and utility (the proportion of all patients who have a negative D-dimer test) when the two strategies are used to interpret D-dimer results. METHODS: Using an established IPD database, we conducted a meta-analysis to compare the two strategies. A bivariate random effects regression model was used to estimate and compare the pooled sensitivity and specificity simultaneously. The pooled NPV and utility of the two strategies was compared using a univariate random effects model. RESULTS: Four studies were eligible for this analysis, with a total of 2554 patients. Overall prevalence of DVT was 12% with substantial heterogeneity between studies (P value < .001). Both strategies have high pooled NPVs (99.8%) with a difference of 0% (95% confidence interval [CI]: -0.1, 0.1). The difference between the pooled specificity of the CPTP-adjusted strategy (57.3%) and the age-adjusted strategy (54.7%) was 2.6% (95% CI: -7.7, 12.8). The CPTP-adjusted strategy (49.4%) has a marginally greater pooled utility compared with the age-adjusted approach (47.4%), with a pooled difference of 1.9% (95% CI: -0.1, 3.9). CONCLUSIONS: Both D-dimer interpretation strategies were associated with a high and similar NPV, and similar utility.

6.
Ned Tijdschr Geneeskd ; 1632019 Nov 07.
Artigo em Holandês | MEDLINE | ID: mdl-31750636

RESUMO

Physicians encounter patients who use antithrombotics in virtually every area of medical specialisation. As antithrombotic use is often chronic, it is important for medication monitoring that physicians have sufficient knowledge of the latest developments, even if they do not prescribe antithrombotics themselves. The risk of thrombosis must be weighed against the risk of bleeding in every patient who is eligible to be treated with antithrombotics. In this article we describe the main indications for treatment with antithrombotics based on articles published within the past five years.

7.
BMJ Open ; 9(10): e031639, 2019 Oct 10.
Artigo em Inglês | MEDLINE | ID: mdl-31601598

RESUMO

INTRODUCTION: Combined with patient history and physical examination, a negative D-dimer can safely rule-out pulmonary embolism (PE). However, the D-dimer test is frequently false positive, leading to many (with hindsight) 'unneeded' referrals to secondary care. Recently, the novel YEARS algorithm, incorporating flexible D-dimer thresholds depending on pretest risk, was developed and validated, showing its ability to safely exclude PE in the hospital environment. Importantly, this was accompanied with 14% fewer computed tomographic pulmonary angiography than the standard, fixed D-dimer threshold. Although promising, in primary care this algorithm has not been validated yet. METHODS AND ANALYSIS: The PECAN (Diagnosing Pulmonary Embolism in the context of Common Alternative diagNoses in primary care) study is a prospective diagnostic study performed in Dutch primary care. Included patients with suspected acute PE will be managed by their general practitioner according to the YEARS diagnostic algorithm and followed up in primary care for 3 months to establish the final diagnosis. To study the impact of the use of the YEARS algorithm, the primary endpoints are the safety and efficiency of the YEARS algorithm in primary care. Safety is defined as the proportion of false-negative test results in those not referred. Efficiency denotes the proportion of patients classified in this non-referred category. Additionally, we quantify whether C reactive protein measurement has added diagnostic value to the YEARS algorithm, using multivariable logistic and polytomous regression modelling. Furthermore, we will investigate which factors contribute to the subjective YEARS item 'PE most likely diagnosis'. ETHICS AND DISSEMINATION: The study protocol was approved by the Medical Ethical Committee Utrecht, the Netherlands. Patients eligible for inclusion will be asked for their consent. Results will be disseminated by publication in peer-reviewed journals and presented at (inter)national meetings and congresses. TRIAL REGISTRATION: NTR 7431.

10.
BMJ Open ; 9(12): e032488, 2019 Dec 29.
Artigo em Inglês | MEDLINE | ID: mdl-31888928

RESUMO

INTRODUCTION: Clinical guidelines recommend non-vitamin K antagonist oral anticoagulants (NOACs) over vitamin K antagonists (VKAs) for stroke prevention in most patients with atrial fibrillation (AF). Frail elderly were under-represented in the landmark NOAC-trials, leaving a knowledge gap on the optimal anticoagulant management (VKA or NOAC) in this increasing population. The aim of the Frail-AF (FRAIL-AF) study is to assess whether switching from international normalised ratio (INR)-guided VKA-management to a NOAC-based treatment strategy compared with continuing VKA-management is safe in frail elderly patients with AF. METHODS AND ANALYSIS: The FRAIL-AF study is a pragmatic, multicentre, open-label, randomised controlled clinical trial. Frail elderly (age ≥75 years plus a Groningen Frailty Indicator score ≥3) who receive VKA-treatment for AF in the absence of a mechanical heart valve or severe mitral valve stenosis will be randomised to switch to a NOAC-based treatment strategy or to continue INR-guided VKA-management. Patients with severe renal impairment (estimated glomerular filtration rate <30 mL/min/1.73 m2) will be excluded from randomisation. Based on existing trial evidence in non-frail patients, we will aim to explore whether NOAC-treatment is superior to VKA-therapy in reducing major or clinically relevant non-major bleeding events. Secondary outcomes include minor bleeding, the composite of ischaemic and haemorrhagic stroke, health-related quality of life and cost-effectiveness. The follow-up period for all subjects is 12 months. ETHICS AND DISSEMINATION: The protocol was approved by the Medical Research Ethics Committee of the University Medical Center Utrecht, the Netherlands and by the Central Committee on Research Involving Human Subjects, the Netherlands. All patients are asked written informed consent. Results are expected in 2022 and will be disseminated through peer-reviewed journals as well as presentations at national and international conferences. TRIAL REGISTRATION NUMBER: EudraCT: 2017-000393-11; The Netherlands Trial Registry: 6721 (FRAIL-AF study).

11.
BMJ Open ; 8(8): e021681, 2018 08 23.
Artigo em Inglês | MEDLINE | ID: mdl-30139900

RESUMO

OBJECTIVES: Patients with atrial fibrillation (AF) are at increased risk of many adverse events, notably stroke. To prevent all adverse outcomes, integrated AF care is advocated though the potential domain for such multidisciplinary management is still unclear. Therefore, insight in the systemic nature of AF and identifying patients at risk of adverse events after oral anticoagulation is needed. The aim of this study is to first describe the risk of hospitalisation and mortality in community-dwelling older patients with AF using anticoagulants, and second to assess the association between traditional cardiac risk factors and these outcomes. DESIGN: A prospective cohort. SETTING: General practice. PARTICIPANTS: 2068 patients with AF using oral anticoagulants. OUTCOME MEASURES: We calculated incidence rates (IRs) of ischaemic stroke, bleeding, hospitalisations and mortality, and compared risk factors using Cox regression between those with and without an adverse event, both for cardiac and non-cardiac causes. RESULTS: During a median follow-up of 2.7 (IQR 2.2-3.0) years, the IR per 100 person-years was 22.1 for hospitalisations and 6.7 for mortality. Non-cardiac events outnumbered cardiac events (IRs 15.7 vs 7.6 per 100 person-years for hospitalisation, p<0.001 and 5.0 vs 1.7, p<0.001 for mortality). As a comparison, the IRs for stroke and major bleeding were 1.7 and 0.8 per 100 person years, respectively. In multivariate models, high age, heart failure and vascular disease were independently associated with all-cause hospitalisation and- in addition to diabetes, previous stroke and renal disease-for all-cause mortality. CONCLUSIONS: In anticoagulated community-dwelling patients with AF, stroke risk is effectively reduced and thus fairly low, whereas risks of hospitalisation and mortality remain high, importantly mainly for non-cardiac causes. Notably high age, heart failure and vascular disease are predictive for such outcomes and may be of value in identifying high-risk patients in the future. TRIAL REGISTRATION NUMBER: NTR3741.


Assuntos
Anticoagulantes/uso terapêutico , Fibrilação Atrial/tratamento farmacológico , Fibrilação Atrial/epidemiologia , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Diabetes Mellitus/epidemiologia , Feminino , Seguimentos , Insuficiência Cardíaca/epidemiologia , Hemorragia/epidemiologia , Hospitalização/estatística & dados numéricos , Humanos , Vida Independente , Nefropatias/epidemiologia , Masculino , Países Baixos/epidemiologia , Acidente Vascular Cerebral/epidemiologia , Doenças Vasculares/epidemiologia
12.
BMJ Open ; 8(4): e019967, 2018 04 20.
Artigo em Inglês | MEDLINE | ID: mdl-29678975

RESUMO

OBJECTIVES: Recent studies in referred populations of patients with superficial venous thrombosis (SVT) report risks of venous thromboembolic (VTE) sequelae (deep vein thrombosis or pulmonary embolism) as high as 25%. Likely, these estimates are lower in non-referred patients, but large-scale population-based studies are lacking. We aimed to estimate the incidence rate of SVT in primary care and quantify its risk of VTE sequelae. DESIGN: A retrospective cohort study, using International Classification of Primary Care coding (K94.02) combined with free text searching (synonyms for SVT) to capture all SVT events. All patients were followed up for 3 months using manual free text searching. SETTING: Primary care. PARTICIPANTS: All patients enlisted with general practitioners within the Utrecht General Practitioner Network between 2010 and 2016 (1 534 845 person-years follow-up). MAIN OUTCOME MEASURES: The incidence rate of SVT was expressed as the number of SVT events per 1000 person-years of follow-up and the 3-month cumulative incidence of VTE events was calculated. Logistic regression analysis was used to compare patients with SVT with and without VTE sequelae. RESULTS: A total of 2008 SVT cases were identified, that is, an SVT incidence rate of 1.31 (95% CI 1.25 to 1.37) per 1000 person-years follow-up, with higher rates notably with increasing age. VTE sequelae occurred in 83 patients; 51 at the time of SVT diagnosis and 32 patients during follow-up (total cumulative incidence of 4.1%; 95% CI 3.3% to 5.1%), and were more frequent in those with an active malignancy (OR 2.19; 95% 0.97 to 4.95) and less frequent in those with varicose veins at baseline (OR 0.57, 95% CI 0.34 to 0.94). CONCLUSION: We found an incidence rate of SVT in primary care of 1.31 per 1000 person-years. The risks of VTE sequelae was relatively low at 4.1%, with the highest risk in patients with cancer and in those who experience an SVT in the absence of varicose veins.


Assuntos
Embolia Pulmonar/epidemiologia , Tromboembolia Venosa/epidemiologia , Trombose Venosa/epidemiologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Bases de Dados Factuais , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Países Baixos/epidemiologia , Atenção Primária à Saúde/estatística & dados numéricos , Recidiva , Estudos Retrospectivos , Fatores de Risco , Adulto Jovem
13.
Heart ; 104(15): 1236-1237, 2018 08.
Artigo em Inglês | MEDLINE | ID: mdl-29549089

RESUMO

OBJECTIVE: Heart failure (HF) often coexists in atrial fibrillation (AF) but is frequently unrecognised due to overlapping symptomatology. Furthermore, AF can cause elevated natriuretic peptide levels, impairing its diagnostic value for HF detection. We aimed to assess the prevalence of previously unknown HF in community-dwelling patients with AF, and to determine the diagnostic value of the amino-terminal pro B-type natriuretic peptide (NTproBNP) for HF screening in patients with AF. METHODS: Individual participant data from four HF-screening studies in older community-dwelling persons were combined. Presence or absence of HF was in each study established by an expert panel following the criteria of the European Society of Cardiology. We performed a two-stage patient-level meta-analysis to calculate traditional diagnostic indices. RESULTS: Of the 1941 individuals included in the four studies, 196 (10.1%) had AF at baseline. HF was uncovered in 83 (43%) of these 196 patients with AF, versus 381 (19.7%) in those without AF at baseline. Median NTproBNP levels of patients with AF with and without HF were 744 pg/mL and 211 pg/mL, respectively. At the cut-point of 125 pg/mL, sensitivity was 93%, specificity 35%, and positive and negative predictive values 51% and 86%, respectively. Only 23% of all patients with AF had an NTproBNP level below the 125 pg/mL cut-point, with still a 13% prevalence of HF in this group. CONCLUSIONS: With a prevalence of nearly 50%, unrecognised HF is common among community-dwelling patients with AF. Given the high prior change, natriuretic peptides are diagnostically not helpful, and straightforward echocardiography seems to be the preferred strategy for HF screening in patients with AF.


Assuntos
Fibrilação Atrial/sangue , Insuficiência Cardíaca/sangue , Insuficiência Cardíaca/diagnóstico , Peptídeo Natriurético Encefálico/sangue , Fragmentos de Peptídeos/sangue , Fibrilação Atrial/complicações , Insuficiência Cardíaca/epidemiologia , Humanos , Prevalência , Sensibilidade e Especificidade
14.
BMJ Open ; 7(9): e015510, 2017 09 18.
Artigo em Inglês | MEDLINE | ID: mdl-28928175

RESUMO

INTRODUCTION: In our ageing society, we are at the merge of an expected epidemic of atrial fibrillation (AF). AF management requires an integrated approach, including rate or rhythm control, stroke prevention with anticoagulation and treatment of comorbidities such as heart failure or type 2 diabetes. As such, primary care seems to be the logical healthcare setting for the chronic management of patients with AF. However, primary care has not yet played a dominant role in AF management, which has been in fact more fragmented between different healthcare providers. This fragmentation might have contributed to high healthcare costs. To demonstrate the feasibility of managing AF in primary care, studies are needed that evaluate the safety and (cost-)effectiveness of integrated AF management in primary care. METHODS AND ANALYSIS: The ALL-IN trial is a multicentre, pragmatic, cluster randomised, non-inferiority trial performed in primary care practices in a suburban region in the Netherlands. We aim to include a minimum of 1000 patients with AF aged 65 years or more from around 18 to 30 practices. Duration of the study is 2 years. Practices will be randomised to either the intervention arm (providing integrated AF management, involving a trained practice nurse and collaboration with secondary care) or the control arm (care as usual). The primary endpoint is all-cause mortality. Secondary endpoints are cardiovascular mortality, (non)-cardiovascular hospitalisation, major adverse cardiac events, stroke, major bleeding, clinically relevant non-major bleeding, quality of life and cost-effectiveness. ETHICS AND DISSEMINATION: The protocol was approved by the Medical Ethical Committee of the Isala Hospital Zwolle, the Netherlands. Patients in the intervention arm will be asked informed consent for participating in the intervention. Results are expected in 2019 and will be disseminated through both national and international journals and conferences. TRIAL REGISTRATION NUMBER: This trial is registered at the Netherlands Trial Register (NTR5532).


Assuntos
Anticoagulantes/uso terapêutico , Fibrilação Atrial/terapia , Prestação Integrada de Cuidados de Saúde/métodos , Atenção Primária à Saúde/métodos , Idoso , Anticoagulantes/efeitos adversos , Fibrilação Atrial/complicações , Fibrilação Atrial/mortalidade , Causas de Morte , Comorbidade , Análise Custo-Benefício , Hemorragia/etiologia , Hospitalização , Humanos , Comunicação Interdisciplinar , Países Baixos , Papel do Profissional de Enfermagem , Qualidade de Vida , Projetos de Pesquisa , Atenção Secundária à Saúde , Acidente Vascular Cerebral/etiologia
15.
BMJ Open ; 7(3): e012789, 2017 03 09.
Artigo em Inglês | MEDLINE | ID: mdl-28279993

RESUMO

OBJECTIVES: To evaluate the extent of delay in the diagnosis of pulmonary embolism (PE) in primary care, and to identify determinants that are associated with such diagnostic delay. DESIGN: Retrospective observational study. SETTING: 6 primary care practices across the Netherlands. PARTICIPANTS: Data from patients with an objectively confirmed diagnosis of PE (International Classification of Primary Care (ICPC) code K93) up to June 2015 were extracted from the electronic medical records. For all these PE events, we reviewed all consultations with their general practitioner (GP) and scored any signs and symptoms that could be attributed to PE in the 3 months prior to the event. Also, we documented actual comorbidity and the diagnosis considered initially. PRIMARY AND SECONDARY OUTCOME MEASURES: Delay was defined as a time gap of >7 days between the first potentially PE-related contact with the GP and the final PE diagnosis. Multivariable logistic regression analysis was performed to identify independent determinants for delay. RESULTS: In total, 180 incident PE cases were identified, of whom 128 patients had 1 or more potential PE-related contact with their GP within the 3 months prior to the diagnosis. Based on our definition, in 33 of these patients (26%), diagnostic delay was observed. Older age (age >75 years; OR 5.1 (95% CI 1.8 to 14.1)) and the absence of chest symptoms (ie, chest pain or pain on inspiration; OR 5.4 (95% CI 1.9 to 15.2)) were independent determinants for diagnostic delay. A respiratory tract infection prior to the PE diagnosis was reported in 13% of cases without delay, and in 33% of patients with delay (p=0.008). CONCLUSIONS: Diagnostic delay of more than 7 days in the diagnosis of PE is common in primary care, especially in the elderly, and if chest symptoms, like pain on inspiration, are absent.


Assuntos
Embolia Pulmonar/diagnóstico , Idoso , Diagnóstico Tardio , Feminino , Medicina Geral/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Países Baixos , Infecções Respiratórias/diagnóstico , Estudos Retrospectivos , Tromboembolia Venosa/diagnóstico
16.
Fam Pract ; 34(4): 446-451, 2017 08 01.
Artigo em Inglês | MEDLINE | ID: mdl-27471223

RESUMO

Background: A clinical decision rule (CDR), combined with a negative D-dimer test, can safely rule out deep venous thrombosis (DVT) in primary care. This strategy is recommended by guidelines, yet uptake by GPs is low. Objective: To evaluate a multi-faceted implementation strategy aimed at increased use of the guideline recommended CDR plus D-dimer test in primary care patients with suspected DVT. Methods: This multi-faceted implementation strategy consisted of educational outreach visits, financial reimbursements and periodical newsletters. 217 Dutch GPs (implementation group) received this strategy and included patients. Effectiveness was measured through the following patient-level outcomes: (i) proportion of non-referred patients, (ii) proportion of missed DVT cases within this group and (iii) the proportion of patients in whom the guideline was applied incorrectly. Implementation outcomes ('acceptability', 'feasibility', 'fidelity' and 'sustainability') were assessed with an online questionnaire. Patient-level outcomes were compared with those of patients included by 450 GPs, uninformed about the study's purposes providing information about usual care. Results: 336 (54%) of 619 analyzable implementation group patients were not referred, missing 6 [1.8% (95% confidence interval 0.7% to 3.9%)] DVT cases. Incorrect guideline use was observed in 199 patients (32%). Self-reported acceptability, feasibility and expected sustainability were high. Guideline use increased from 42% to an expected continuation of use of 91%. Only 32 usual care GPs included 62 patients, making formal comparison unreliable. Conclusions: This multi-faceted implementation strategy safely reduced patient referral to secondary care, despite frequently incorrect application of the guideline and resulted in high acceptability, feasibility and expected sustainability.


Assuntos
Técnicas de Apoio para a Decisão , Implementação de Plano de Saúde/normas , Atenção Primária à Saúde/normas , Trombose Venosa/diagnóstico , Feminino , Produtos de Degradação da Fibrina e do Fibrinogênio , Clínicos Gerais/educação , Guias como Assunto/normas , Humanos , Masculino , Pessoa de Meia-Idade , Motivação , Países Baixos , Atenção Primária à Saúde/métodos , Encaminhamento e Consulta , Inquéritos e Questionários
17.
Ann Fam Med ; 14(3): 227-34, 2016 05.
Artigo em Inglês | MEDLINE | ID: mdl-27184993

RESUMO

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.


Assuntos
Produtos de Degradação da Fibrina e do Fibrinogênio/análise , Embolia Pulmonar/diagnóstico , Tromboembolia Venosa/diagnóstico , Adulto , Idoso , Área Sob a Curva , Biomarcadores/sangue , Reações Falso-Negativas , Reações Falso-Positivas , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Países Baixos , Sistemas Automatizados de Assistência Junto ao Leito , Valor Preditivo dos Testes , Atenção Primária à Saúde , Probabilidade , Estudos Prospectivos , Embolia Pulmonar/sangue , Tromboembolia Venosa/sangue
18.
BMJ ; 351: h4438, 2015 Sep 08.
Artigo em Inglês | MEDLINE | ID: mdl-26349907

RESUMO

OBJECTIVE: To validate all diagnostic prediction models for ruling out pulmonary embolism that are easily applicable in primary care. DESIGN: Systematic review followed by independent external validation study to assess transportability of retrieved models to primary care medicine. SETTING: 300 general practices in the Netherlands. PARTICIPANTS: Individual patient dataset of 598 patients with suspected acute pulmonary embolism in primary care. MAIN OUTCOME MEASURES: Discriminative ability of all models retrieved by systematic literature search, assessed by calculation and comparison of C statistics. After stratification into groups with high and low probability of pulmonary embolism according to pre-specified model cut-offs combined with qualitative D-dimer test, sensitivity, specificity, efficiency (overall proportion of patients with low probability of pulmonary embolism), and failure rate (proportion of pulmonary embolism cases in group of patients with low probability) were calculated for all models. RESULTS: Ten published prediction models for the diagnosis of pulmonary embolism were found. Five of these models could be validated in the primary care dataset: the original Wells, modified Wells, simplified Wells, revised Geneva, and simplified revised Geneva models. Discriminative ability was comparable for all models (range of C statistic 0.75-0.80). Sensitivity ranged from 88% (simplified revised Geneva) to 96% (simplified Wells) and specificity from 48% (revised Geneva) to 53% (simplified revised Geneva). Efficiency of all models was between 43% and 48%. Differences were observed between failure rates, especially between the simplified Wells and the simplified revised Geneva models (failure rates 1.2% (95% confidence interval 0.2% to 3.3%) and 3.1% (1.4% to 5.9%), respectively; absolute difference -1.98% (-3.33% to -0.74%)). Irrespective of the diagnostic prediction model used, three patients were incorrectly classified as having low probability of pulmonary embolism; pulmonary embolism was diagnosed only after referral to secondary care. CONCLUSIONS: Five diagnostic pulmonary embolism prediction models that are easily applicable in primary care were validated in this setting. Whereas efficiency was comparable for all rules, the Wells rules gave the best performance in terms of lower failure rates.


Assuntos
Técnicas de Apoio para a Decisão , Embolia Pulmonar/diagnóstico , Feminino , Produtos de Degradação da Fibrina e do Fibrinogênio/análise , Humanos , Masculino , Pessoa de Meia-Idade , Atenção Primária à Saúde/métodos , Fatores de Risco , Sensibilidade e Especificidade
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