Stoffers H E, Kester A D, Kaiser V, Rinkens P E, Knottnerus J A
Department of General Practice, University of Limburg, Maastricht, The Netherlands.
Med Decis Making. 1997 Jan-Mar;17(1):61-70. doi: 10.1177/0272989X9701700107.
To assess the diagnostic values of single and combined data from the history, physical examination, and medical record with regard to peripheral arterial occlusive disease (PAOD) in patients with leg complaints; to construct a multivariable model for the clinical diagnosis of PAOD by primary care physicians.
18 general practice centers in The Netherlands.
Cross-sectional comparison of signs, symptoms, and data from the medical record with the independently assessed ankle-brachial systolic pressure index (ABPI; cutoff point < 0.90); analysis: bivariate, multiple logistic regression (MLR).
2,455 individuals with leg complaints, aged 40.7-78.4 years; ABPI < 0.90 present in 9.2% of legs (11.7% of individuals).
Clinical variables: sensitivity, specificity, positive and negative predictive values (PV+, PV-), diagnostic odds ratio (OR); models: likelihood ratio test, area under the receiver operating characteristic curve (AUC).
Bivariate analysis: highest sensitivity: age more than 60 years (77.3%); highest specificity: wounds or sores on toes and foot (99.7%); highest PV+: typical intermittent claudication (IC) (45.0%) (abnormal foot pulses 41.3%); highest PV-: strong pulses of both foot arteries (97.7%). MRL: the best-performing model (AUC 0.89) consisted of ten clinical variables: gender (OR 1.5), age more than 60 (OR 2.2); IC (OR 3.5); palpation of the skin temperature of the feet (OR 2.5), palpation of both foot pulses [OR 16.4 (abnormal) and 7.0 (doubtful)], auscultation of the femoral artery (OR 3.5); previous diagnosis of IHD (OR 1.7) or diabetes (OR 1.6), history of smoking (OR 2.1), and elevated blood pressure (OR 1.5). The range of predicted probabilities was 0.4-98%. The Hosmer-Lemeshow goodness-of-fit test indicated good overall fit (p = 52).
Palpation of both foot pulses is the key procedure for the clinical diagnosis of PAOD. Traditional clinical evaluation enables the general practitioner to exclude the diagnosis of PAOD in many individuals with a high degree of certainly, to establish the diagnosis in a small group of patients, and to define a limited group of patients where supplementary noninvasive testing is appropriate. The MLR model can be used as a diagnostic checklist and as a reference for the physician's clinical hypothesis.
评估病史、体格检查和病历中的单一数据及综合数据对有腿部不适患者外周动脉闭塞性疾病（PAOD）的诊断价值；构建由基层医疗医生用于PAOD临床诊断的多变量模型。
荷兰的18个全科医疗中心。
将体征、症状和病历数据与独立评估的踝臂收缩压指数（ABPI；临界值<0.90）进行横断面比较；分析：双变量、多元逻辑回归（MLR）。
2455名有腿部不适的个体，年龄在40.7 - 78.4岁之间；9.2%的腿部（11.7%的个体）ABPI<0.90。
临床变量：敏感性、特异性、阳性和阴性预测值（PV +、PV -）、诊断比值比（OR）；模型：似然比检验、受试者工作特征曲线下面积（AUC）。
双变量分析：最高敏感性：年龄超过60岁（77.3%）；最高特异性：脚趾和足部有伤口或溃疡（99.7%）；最高PV +：典型间歇性跛行（IC）（45.0%）（足部脉搏异常为41.3%）；最高PV -：双脚动脉搏动有力（97.7%）。MLR：表现最佳的模型（AUC 0.89）由10个临床变量组成：性别（OR 1.5）、年龄超过60岁（OR 2.2）；IC（OR 3.5）；足部皮肤温度触诊（OR 2.5）、双脚脉搏触诊[OR 16.4（异常）和7.0（可疑）]、股动脉听诊（OR 3.5）；既往缺血性心脏病（IHD）诊断（OR 1.7）或糖尿病诊断（OR 1.6）、吸烟史（OR 2.1）以及血压升高（OR 1.5）。预测概率范围为0.4 - 98%。Hosmer - Lemeshow拟合优度检验表明整体拟合良好（p = 52）。
双脚脉搏触诊是PAOD临床诊断的关键步骤。传统临床评估使全科医生能够在很大程度上确定性地排除许多个体的PAOD诊断，在一小部分患者中确立诊断，并确定一小部分适合进行补充无创检测的患者。MLR模型可作为诊断清单和医生临床假设的参考。
