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[Validation of a deep vein thrombosis prediction rule in primary care.]

[Validation of a deep vein thrombosis prediction rule in primary care.]

J Mal Vasc. 2011 Dec 12;

Authors: Maufus M, Bosson JL, Genty C, Delluc A, Imbert P, Gagne P, Rolland C, Bressollette L, Le Gal G

Abstract
OBJECTIVE: Suspected deep vein thrombosis (DVT) of lower limbs (LL) may require different tools to rule out or confirm the diagnosis. Clinical probability provides help to select useful tests, interpret their results, and decide to treat the patient meanwhile. Clinical prediction rules that risk stratify patients with suspected DVT can be established from inpatients, but no prediction rule not requiring laboratory tests has been established from primary care patients. We previously derived and internally validated such a prediction rule. The aim of this study is to externally validate this score. PATIENTS AND METHODS: The score was applied to Optimev outpatients with suspected LL-DVT, and without suspected pulmonary embolism. Sensitivity and specificity were calculated for proximal and distal DVT, according to each score. The area under the ROC curve was calculated for each kind of DVT, in order to assess the validity of the score on predicting the presence or absence of DVT. RESULTS: Among 3523 outpatients prospectively included in the Optimev study for suspected LL DVT, overall prevalence of DVT was 29.7% (n=1046), ranging from 21.7% in the non-high score probability, to 61.4% in the high score probability. The area under the ROC curve was 0.79 [CI 95%, 0.77-0.80]. With subgroup analysis, the area under curve was 0.83 [CI 95%, 0.82-0.85] for proximal DVT, and 0.75 [CI 95%, 0.73-0.77] for distal DVT. CONCLUSION: This score reliably identifies primary care patients with LL DVT, whether proximal or distal.

PMID: 22169238 [PubMed - as supplied by publisher]

Diagnostic Accuracy of Pulmonary Embolism Rule-Out Criteria: A Systematic Review and Meta-analysis.

Diagnostic Accuracy of Pulmonary Embolism Rule-Out Criteria: A Systematic Review and Meta-analysis.

Ann Emerg Med. 2011 Dec 14;

Authors: Singh B, Parsaik AK, Agarwal D, Surana A, Mascarenhas SS, Chandra S

Abstract
STUDY OBJECTIVE: To perform a systematic review and meta-analysis to define the diagnostic performance of pulmonary embolism rule-out criteria (PERC) in deferring the need for D-dimer testing to rule out pulmonary embolism in the emergency department (ED). METHODS: We searched EMBASE, MEDLINE, Scopus, Web of Knowledge, and all the evidence-based medicine reviews that included the Cochrane Database of Systematic Reviews through August 14, 2011, and hand searched references in potentially eligible articles and conference proceedings of major emergency medicine organizations for the previous 2 years. We selected studies that reported diagnostic performance of PERC, reported original research, and were conducted in the ED, with no language restrictions. Two investigators independently identified eligible studies and extracted data. We used contingency tables to calculate sensitivity, specificity, and likelihood ratios. RESULTS: We found 12 qualifying cohorts (studying 13,885 patients with 1,391 pulmonary embolism diagnoses), 10 prospective and 2 retrospective, from 6 countries. Pooled sensitivity, specificity, positive likelihood ratios, and negative likelihood ratios for 10 included studies were 0.97 (95% confidence interval [CI] 0.96 to 0.98), 0.23 (95% CI 0.22 to 0.24), 1.24 (95% CI 1.18 to 1.30), and 0.17 (95% CI 0.13 to 0.23), respectively. Significant heterogeneity was observed in specificity (I(2)=97.2%) and positive likelihood ratio (I(2)=84.2%). CONCLUSION: The existing literature suggests consistently high sensitivity and low but acceptable specificity of the PERC to rule out pulmonary embolism in patients with low pretest probability.

PMID: 22177109 [PubMed - as supplied by publisher]

Evaluation of the use of venous thromboembolism prophylaxis in hospitalised medical patients.

BACKGROUND: Venous thromboembolism (VTE) prophylaxis is effective in the prevention of deep vein thrombosis (DVT) and pulmonary embolism (PE) in medical patients.

METHODS: A retrospective chart review was performed on medical inpatients at two academic hospitals in Hamilton, Ontario to investigate if patients received VTE prophylaxis as per current guidelines.

RESULTS: An analysis was performed on 762 patient charts and 170 met inclusion criteria for use of pharmacological VTE prophylaxis. Of these, 91 (54%) received pharmacological VTE prophylaxis. In 63 patients with a contraindication to pharmacological VTE prophylaxis, 16 (25%) received non-pharmacological VTE prophylaxis.

CONCLUSION: The provision rate of pharmacological VTE prophylaxis in hospitalised medical patients who met pre-defined clinical criteria for prophylaxis was 54%. The rate of prophylaxis increased with additional VTE risk factors to a peak rate of 67%. There is room for the development of strategies to improve the use of VTE prophylaxis in hospitalised medical patients.

Effect of Computerized Clinical Decision Support on the Use and Yield of CT Pulmonary Angiography in the Emergency Department.

Purpose: To determine the effect of evidence-based clinical decision support (CDS) on the use and yield of computed tomographic (CT) pulmonary angiography for acute pulmonary embolism (PE) in the emergency department (ED).

Materials and Methods:Institutional review board approval was obtained for this HIPAA-compliant study, which was performed between October 1, 2003, and September 30, 2009, at a 793-bed quaternary care institution with 60 000 annual ED visits. Use (number of examinations per 1000 ED visits) and yield (percentage of examinations positive for acute PE) of CT pulmonary angiography were compared before and after CDS implementation in August 2007. The authors included all adult patients presenting to the ED and developed and validated a natural language processing tool to identify acute PE diagnoses. Linear trend analysis was used to assess for variation in CT pulmonary angiography use. Logistic regression was used to determine variation in yield after controlling for patient demographic and clinical characteristics.

Results:Of 338 230 patients presenting to the ED, 6838 (2.0%) underwent CT pulmonary angiography. Quarterly CT pulmonary angiography use increased 82.1% before CDS implementation, from 14.5 to 26.4 examinations per 1000 patients (P < .0001) between October 10, 2003, and July 31, 2007. After CDS implementation, quarterly use decreased 20.1%, from 26.4 to 21.1 examinations per 1000 patients between August 1, 2007, and September 30, 2009 (P = .0379). Overall, 686 (10.0%) of the CT pulmonary angiographic examinations performed during the 6-year period were positive for PE; subsequent to CDS implementation, yield by quarter increased 69.0%, from 5.8% to 9.8% (P = .0323).

Conclusion:Implementation of evidence-based CDS in the ED was associated with a significant decrease in use, and increase in yield, of CT pulmonary angiography for the evaluation of acute PE.© RSNA, 2011.

Evidence-based Venous Thromboembolism Prophylaxis is Associated With a Six-fold Decrease in Numbers of Symptomatic Venous Thromboembolisms in Rehabilitation Inpatients.

OBJECTIVES: To measure the impact of a standardized risk assessment tool and specialty-specific, risk-adjusted venous thromboembolism (VTE) order sets on compliance with American College of Chest Physicians (ACCP) guidelines and the number of symptomatic VTE as assessed by administrative data.

DESIGN: Prospective cohort study.
SETTING: Academic hospital inpatient rehabilitation unit.

PATIENTS AND PARTICIPANTS: All patients on the rehabilitation unit. METHODS AND INTERVENTIONS: Assessment of VTE risk factors and evaluated admission VTE prophylaxis orders before and after implementation of an ACCP guideline-based, specialty-specific VTE risk assessment, and prophylaxis order set by using a standardized data collection form.

MAIN OUTCOME MEASURES: Discharge diagnostic codes for VTE and pulmonary embolism were tracked by ICD-9 (International Classification of Diseases, 9th edition) discharge diagnosis codes for the 12 months before and 36 months after the intervention.

RESULTS: Before implementation of the VTE order set, 27% of patients received VTE prophylaxis in compliance with the 2004 ACCP VTE guidelines. By following implementation of specialty-specific, risk-adjusted VTE order sets, compliance increased to 98%. In the year before VTE order-set implementation, the number of VTEs per admission was 49 per 1000. By following implementation, the number of VTEs steadily decreased each year to 8 per 1000 in 2007 (χ(2) = 14.985; P = .0001).

CONCLUSIONS: Implementation of a standardized VTE risk assessment tool and prophylaxis order set resulted in a substantial improvement in compliance with ACCP guidelines for VTE prophylaxis and was associated with a 6-fold reduction in the number of symptomatic VTEs in a hospital-based rehabilitation unit.

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