Real-life impact of clinical prediction rules for venous thromboembolism in primary care: a cross-sectional cohort study
Objective Clinical prediction rules (CPRs) followed by D-dimer testing were shown to safely rule out venous thromboembolism (VTE) in about half of all suspected patients in controlled and experienced study settings. Yet, its real-life impact in primary care is unknown. The aim of this study was to d...
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BMJ Publishing Group
2020-12-01
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| Series: | BMJ Open |
| Online Access: | https://bmjopen.bmj.com/content/10/12/e039913.full |
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| author | Frans H Rutten Rosanne van Maanen Geert-Jan Geersing Ruud Oudega Karel Moons Anna E C Kingma |
| author_facet | Frans H Rutten Rosanne van Maanen Geert-Jan Geersing Ruud Oudega Karel Moons Anna E C Kingma |
| author_sort | Frans H Rutten |
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| description | Objective Clinical prediction rules (CPRs) followed by D-dimer testing were shown to safely rule out venous thromboembolism (VTE) in about half of all suspected patients in controlled and experienced study settings. Yet, its real-life impact in primary care is unknown. The aim of this study was to determine the real-life impact of CPRs for suspected VTE in primary care.Design Cross-sectional cohort study.Setting Primary care in the Netherlands.Participants Patients with suspected deep venous thrombosis (n=993) and suspected pulmonary embolism (n=484).Interventions General practitioners received an educational instruction on how to use CPRs in suspected VTE. We did not rectify incorrect application of the CPR in order to mimic daily clinical care.Main outcome measures Primary outcomes were the diagnostic failure rate, defined as the 3-month incidence of VTE in the non-referred group, and the efficiency, defined as the proportion of non-referred patients in the total study population. Secondary outcomes were determinants for and consequences of incorrect application of the CPRs.Results In 267 of the included 1477 patients, VTE was confirmed. When CPRs were correctly applied, the failure rate was 1.51% (95% CI 0.77 to 2.86), and the efficiency was 58.1% (95% CI 55.2 to 61.0). However, the CPRs were incorrectly applied in 339 patients, which resulted in an increased failure rate of 3.31% (95% CI 1.07 to 8.76) and a decreased efficiency of 35.7% (95% CI 30.6 to 41.1). The presence of concurrent heart failure increased the likelihood of incorrect application (adjusted OR 3.26; 95% CI 1.47 to 7.21).Conclusions Correct application of CPRs for VTE in primary care is associated with an acceptable low failure rate at a high efficiency. Importantly, in nearly a quarter of patients, the CPRs were incorrectly applied that resulted in a higher failure rate and a considerably lower efficiency. |
| format | Article |
| id | doaj-art-d65d0ee652db4e5e8b4e067a8404de3b |
| institution | Kabale University |
| issn | 2044-6055 |
| language | English |
| publishDate | 2020-12-01 |
| publisher | BMJ Publishing Group |
| record_format | Article |
| series | BMJ Open |
| spelling | doaj-art-d65d0ee652db4e5e8b4e067a8404de3b2024-11-22T01:00:09ZengBMJ Publishing GroupBMJ Open2044-60552020-12-01101210.1136/bmjopen-2020-039913Real-life impact of clinical prediction rules for venous thromboembolism in primary care: a cross-sectional cohort studyFrans H Rutten0Rosanne van Maanen1Geert-Jan Geersing2Ruud Oudega3Karel Moons4Anna E C Kingma5Department of General Practice and Nursing Science, Julius Center for Health Sciences and Primary Care, Utrecht, NetherlandsDepartment of General Practice, Julius Center for Health Sciences and Primary Care, University Medical Center, Utrecht, NetherlandsJulius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The NetherlandsJulius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The NetherlandsCochrane Netherlands, University Medical Center Utrecht, University of Utrecht, Utrecht, The NetherlandsJulius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The NetherlandsObjective Clinical prediction rules (CPRs) followed by D-dimer testing were shown to safely rule out venous thromboembolism (VTE) in about half of all suspected patients in controlled and experienced study settings. Yet, its real-life impact in primary care is unknown. The aim of this study was to determine the real-life impact of CPRs for suspected VTE in primary care.Design Cross-sectional cohort study.Setting Primary care in the Netherlands.Participants Patients with suspected deep venous thrombosis (n=993) and suspected pulmonary embolism (n=484).Interventions General practitioners received an educational instruction on how to use CPRs in suspected VTE. We did not rectify incorrect application of the CPR in order to mimic daily clinical care.Main outcome measures Primary outcomes were the diagnostic failure rate, defined as the 3-month incidence of VTE in the non-referred group, and the efficiency, defined as the proportion of non-referred patients in the total study population. Secondary outcomes were determinants for and consequences of incorrect application of the CPRs.Results In 267 of the included 1477 patients, VTE was confirmed. When CPRs were correctly applied, the failure rate was 1.51% (95% CI 0.77 to 2.86), and the efficiency was 58.1% (95% CI 55.2 to 61.0). However, the CPRs were incorrectly applied in 339 patients, which resulted in an increased failure rate of 3.31% (95% CI 1.07 to 8.76) and a decreased efficiency of 35.7% (95% CI 30.6 to 41.1). The presence of concurrent heart failure increased the likelihood of incorrect application (adjusted OR 3.26; 95% CI 1.47 to 7.21).Conclusions Correct application of CPRs for VTE in primary care is associated with an acceptable low failure rate at a high efficiency. Importantly, in nearly a quarter of patients, the CPRs were incorrectly applied that resulted in a higher failure rate and a considerably lower efficiency.https://bmjopen.bmj.com/content/10/12/e039913.full |
| spellingShingle | Frans H Rutten Rosanne van Maanen Geert-Jan Geersing Ruud Oudega Karel Moons Anna E C Kingma Real-life impact of clinical prediction rules for venous thromboembolism in primary care: a cross-sectional cohort study BMJ Open |
| title | Real-life impact of clinical prediction rules for venous thromboembolism in primary care: a cross-sectional cohort study |
| title_full | Real-life impact of clinical prediction rules for venous thromboembolism in primary care: a cross-sectional cohort study |
| title_fullStr | Real-life impact of clinical prediction rules for venous thromboembolism in primary care: a cross-sectional cohort study |
| title_full_unstemmed | Real-life impact of clinical prediction rules for venous thromboembolism in primary care: a cross-sectional cohort study |
| title_short | Real-life impact of clinical prediction rules for venous thromboembolism in primary care: a cross-sectional cohort study |
| title_sort | real life impact of clinical prediction rules for venous thromboembolism in primary care a cross sectional cohort study |
| url | https://bmjopen.bmj.com/content/10/12/e039913.full |
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