Department of General Practice, Vascular Medicine and Clinical Epidemiology, University of Amsterdam, The Netherlands.
Ann Fam Med. 2011 Jan-Feb;9(1):31-6. doi: 10.1370/afm.1198.
The Wells rule is widely used for clinical assessment of patients with suspected deep vein thrombosis (DVT), especially in the secondary care setting. Recently a new clinical decision rule for primary care patients (the primary care rule) has been proposed, because the Wells rule is not sufficient to rule out DVT in this setting. The objective was to compare the ability of both rules to safely rule out DVT and to efficiently reduce the number of referrals for leg ultrasound investigation that would result in a negative finding.
Family physicians collected data on 1,086 patients to calculate the scores for both decision rules before leg ultrasonography was performed. In all patients D-dimer (dimerized plasmin fragment D) testing was performed using a rapid point-of-care assay. Patients were stratified into risk categories defined by each rule and the D-dimer result. Outcomes were DVT (diagnosed by ultrasonography) and venous thromboembolic complications or death caused by a possible thromboembolic event during a 90-day follow-up period. We calculated the differences between the 2 rules in the number of missed diagnoses and the proportions of patients that needed ultrasound testing.
Data from 1,002 eligible patients were used for this analysis. A venous thromboembolic event occurred during follow-up in 7 patients with a low score and negative D-dimer finding, both with the Wells rule (7 of 447; 1.6%; 95% confidence interval [CI], 0.7%-3.3% ) and the primary care rule (7 of 495; 1.4%; 95% CI, 0.6%-3.0%). Using the Wells rule, 447 patients (45%) would not need referral for further testing compared with 495 patients (49%) when using the primary care rule (McNemar P <.001).
In primary care, suspected DVT can safely be ruled out using either of the 2 rules in combination with a point-of-care D-dimer test. Both rules can reduce unnecessary referrals for compression ultrasonography by about 50%, though the primary care rule reduces it slightly more.
Wells 评分广泛用于疑似深静脉血栓形成（DVT）患者的临床评估，尤其是在二级保健环境中。最近，提出了一种新的用于初级保健患者的临床决策规则（初级保健规则），因为 Wells 评分在这种情况下不足以排除 DVT。目的是比较这两种规则安全排除 DVT 的能力，并有效地减少因阴性发现而导致的腿部超声检查转诊数量。
家庭医生在进行腿部超声检查之前收集了 1086 名患者的数据，以计算出两种决策规则的评分。所有患者均使用即时护理点检测进行 D-二聚体（二聚化纤溶酶片段 D）检测。根据每个规则和 D-二聚体结果，将患者分为风险类别。结局为 DVT（通过超声诊断）和静脉血栓栓塞并发症或 90 天随访期间因可能的血栓栓塞事件导致的死亡。我们计算了两种规则在漏诊数量和需要超声检查的患者比例方面的差异。
对 1002 名合格患者的数据进行了此项分析。在 Wells 规则（447 例中有 7 例，7/447；95%置信区间[CI]，0.7%-3.3%）和初级保健规则（495 例中有 7 例，7/495；95%CI，0.6%-3.0%）中，低评分且 D-二聚体阴性发现的 7 例患者在随访期间发生静脉血栓栓塞事件。使用 Wells 规则，与使用初级保健规则相比，447 例患者（45%）无需进一步检查转诊，而使用初级保健规则则有 495 例患者（49%）（McNemar P <.001）。
在初级保健中，疑似 DVT 可以安全地使用这两种规则中的任何一种与即时护理点 D-二聚体检测相结合进行排除。两种规则都可以减少大约 50%的不必要的压缩超声检查转诊，尽管初级保健规则的转诊减少略多一些。
