Hendriksen Janneke M T, Geersing Geert-Jan, Lucassen Wim A M, Erkens Petra M G, Stoffers Henri E J H, van Weert Henk C P M, Büller Harry R, Hoes Arno W, Moons Karel G M
Department of Epidemiology, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, 3508 GA Utrecht, Netherlands
Department of Epidemiology, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, 3508 GA Utrecht, Netherlands.
BMJ. 2015 Sep 8;351:h4438. doi: 10.1136/bmj.h4438.
To validate all diagnostic prediction models for ruling out pulmonary embolism that are easily applicable in primary care.
Systematic review followed by independent external validation study to assess transportability of retrieved models to primary care medicine.
300 general practices in the Netherlands.
Individual patient dataset of 598 patients with suspected acute pulmonary embolism in primary care.
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.
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.
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.
验证所有易于在初级保健中应用的排除肺栓塞的诊断预测模型。
系统评价，随后进行独立的外部验证研究，以评估检索到的模型在初级保健医学中的可移植性。
荷兰的300家普通诊所。
598例初级保健中疑似急性肺栓塞患者的个体患者数据集。
通过系统文献检索获得的所有模型的判别能力，通过计算和比较C统计量进行评估。根据预先设定的模型临界值结合定性D-二聚体检测，将患者分为肺栓塞高概率组和低概率组后，计算所有模型的敏感性、特异性、效率（肺栓塞低概率患者的总体比例）和失败率（肺栓塞低概率组中肺栓塞病例的比例）。
发现了10个已发表的肺栓塞诊断预测模型。其中5个模型可在初级保健数据集中得到验证：原始Wells模型、改良Wells模型、简化Wells模型、修订Geneva模型和简化修订Geneva模型。所有模型的判别能力相当（C统计量范围为0.75-0.80）。敏感性范围为88%（简化修订Geneva模型）至96%（简化Wells模型），特异性范围为48%（修订Geneva模型）至53%（简化修订Geneva模型）。所有模型的效率在43%至48%之间。观察到失败率存在差异，尤其是简化Wells模型和简化修订Geneva模型之间（失败率分别为1.2%（95%置信区间0.2%至3.3%）和3.1%（1.4%至5.9%）；绝对差异-1.98%（-3.33%至-0.74%））。无论使用何种诊断预测模型，均有3例患者被错误分类为肺栓塞低概率；仅在转诊至二级保健后才诊断出肺栓塞。
在本研究中验证了5个易于在初级保健中应用的诊断肺栓塞预测模型。虽然所有规则的效率相当，但Wells规则在较低失败率方面表现最佳。
Zotero 插件
