Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.
BMJ Open. 2020 Dec 28;10(12):e039913. doi: 10.1136/bmjopen-2020-039913.
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.
Cross-sectional cohort study.
Primary care in the Netherlands.
Patients with suspected deep venous thrombosis (n=993) and suspected pulmonary embolism (n=484).
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.
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 application of the CPRs.
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).
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.
临床预测规则（CPR）结合 D-二聚体检测，在控制和经验丰富的研究环境中，可安全排除约一半疑似静脉血栓栓塞症（VTE）患者。然而，其在初级保健中的实际影响尚不清楚。本研究旨在确定初级保健中用于疑似 VTE 的 CPR 的实际影响。
横断面队列研究。
荷兰初级保健。
疑似深静脉血栓形成（n=993）和疑似肺栓塞（n=484）的患者。
全科医生接受了关于如何在疑似 VTE 中使用 CPR 的教育指导。我们没有纠正 CPR 的不正确应用，以模拟日常临床护理。
主要结局是诊断失败率，定义为非转诊组 3 个月的 VTE 发生率；以及效率，定义为总研究人群中非转诊患者的比例。次要结局是应用 CPR 的决定因素和后果。
在纳入的 1477 例患者中的 267 例中，VTE 得到证实。当正确应用 CPR 时，失败率为 1.51%（95%CI，0.77 至 2.86），效率为 58.1%（95%CI，55.2 至 61.0）。然而，在 339 例患者中 CPR 应用不正确，导致失败率增加至 3.31%（95%CI，1.07 至 8.76），效率降低至 35.7%（95%CI，30.6 至 41.1）。同时存在心力衰竭会增加 CPR 应用不正确的可能性（校正 OR 3.26；95%CI，1.47 至 7.21）。
在初级保健中正确应用 VTE 的 CPR 可实现较低的失败率和较高的效率。重要的是，在近四分之一的患者中，CPR 应用不正确，导致失败率更高，效率大大降低。
