Abstract Purpose Diagnostic prediction models such as the Wells rule can be used for safely ruling out pulmonary embolism (PE) when it is suspected. A physician's own probability estimate ...(“gestalt”), however, is commonly used instead. We evaluated the diagnostic performance of both approaches in primary care. Methods Family physicians estimated the probability of PE on a scale of 0% to 100% (gestalt) and calculated the Wells rule score in 598 patients with suspected PE who were thereafter referred to secondary care for definitive testing. We compared the discriminative ability (c statistic) of both approaches. Next, we stratified patients into PE risk categories. For gestalt, a probability of less than 20% plus a negative point-of-care D-dimer test indicated low risk; for the Wells rule, we used a score of 4 or lower plus a negative D-dimer test. We compared sensitivity, specificity, efficiency (percentage of low-risk patients in total cohort), and failure rate (percentage of patients having PE within the low-risk category). Results With 3 months of follow-up, 73 patients (12%) were confirmed to have venous thromboembolism (a surrogate for PE at baseline). The c statistic was 0.77 (95% CI, 0.70–0.83) for gestalt and 0.80 (95% CI, 0.75–0.86) for the Wells rule. Gestalt missed 2 out of 152 low-risk patients (failure rate = 1.3%; 95% CI, 0.2%–4.7%) with an efficiency of 25% (95% CI, 22%–29%); the Wells rule missed 4 out of 272 low-risk patients (failure rate = 1.5%; 95% CI, 0.4%–3.7%) with an efficiency of 45% (95% CI, 41%–50%). Conclusions Combined with D-dimer testing, both gestalt using a cutoff of less than 20% and the Wells rule using a score of 4 or lower are safe for ruling out PE in primary care. The Wells rule is more efficient, however, and PE can be ruled out in a larger proportion of suspected cases.
Abstract Purpose 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. Methods 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. Results 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). Conclusions 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.
Objective This study assessed the feasibility of the Chronic Disease Self-Management Program (CDSMP) among patients with congestive heart failure (CHF). The program emphasizes patients' central role ...and responsibility in managing their illness. Methods Patients were randomly assigned to the program, which was led by a cardiac nurse specialist and a CHF patient. Data on performance according to protocol, adherence, and opinion about the program were collected among 186 patients and 18 leaders. Results Eighty percent of the group sessions were carried out largely according to protocol. Three fourths of the patients attended at least 4 of the 6 sessions. Female sex and lower New York Heart Association classification predicted good attendance. Conclusion Directly after the program and at 12-month follow-up, approximately three fourths of the patients stated that they had benefited from the program. Recommendations mainly concerned spending more time on several program topics and specifying patient-selection criteria in more detail. The program was considered feasible.
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