A Retrospective Review of the Appropriateness of D-Dimer Ordering and Interpretation Using Wells' Clinical Probability Criteria
Notice bibliographique
Résumé
Introduction The D-dimer has been validated in diagnostic venous thromboembolism (VTE) algorithms. The high sensitivity of the assay allows for safe exclusion of VTE in patients with low clinical pre-test probability and a negative D-dimer. The Wells score for Deep Vein Thrombosis (DVT) and Pulmonary Embolism (PE) are validated pre-test probability tools which help guide physicians on when to order a D-dimer in patients with suspected VTE. However, we suspect these scoring tools are often under-utilized by physicians leading to inappropriate D-dimer ordering and subsequent interventions. We sought to explore the landscape of D-dimer ordering at our institution. Methods We conducted a retrospective chart review of 482 patients in whom a D-dimer had been ordered over a 3-month period at the University of Alberta Hospital, a tertiary care teaching hospital in Edmonton, Canada. Charts were reviewed for patient demographics, specialty of ordering physician, apparent indication for ordering, patient risk factors for VTE and evidence of a pre-test probability (PTP) calculation. WIf no PTP score was documented, we retrospectively calculated Wells DVT or PE scores. VTE was deemed likely with a calculated Wells score for DVT ≧2 or Wells score for PE >4. In the case of high PTP for PE, patients should go directly to imaging and a D-dimer should not be performed. A cut off of ≥ 0.50 mg/L was deemed a positive D-dimer (STA-LIATEST). We also reviewed subsequent investigations thought to be influenced by interpretation of the D-dimer including: ventilation/perfusion (V/Q) and pulmonary angiography (CTPA) scans, and upper and lower extremity doppler ultrasound studies. We then used multivariable logistic regression analysis to evaluate the proportion of patients who received imaging despite a low PTP and negative D-dimer. Results Seventy eight percent of D-dimers were ordered by Emergency physicians while 15.3% were drawn on admitted patients, and 5.8% in the outpatient setting. The indication for ordering was unknown in 87 (17.5%) of cases. Pre-test probability scores were documented in only 8 (1.6%) of cases. All of those documented were the Wells PE score. When Wells DVT and PE scores were calculated retrospectively, 30.0% and 17.1% (87 cases) were deemed 'likely' for VTE, respectively. However, imaging was performed in 172 cases (34.6%), including in 36 cases despite a negative D-dimer result and low PTP. In contrast, 68 cases (17.2%) had a D-dimer performed with a high Wells PTP for PE despite the recommendation to proceed directly to imaging. VTE (either DVT or PE) was confirmed by imaging in 32 (18.6%) of cases, the majority (53.1%) had a high retrospective PTP. Conclusions Inappropriate ordering and interpretation of D-dimers remains a significant problem despite the implementation of clinical guidelines and pre-test probability algorithms, namely the Wells score for DVT and PE meant to guide physicians. This leads to unnecessary cost, radiation exposure, and prolonged contact with the health care system for patients. This suggests the need for quality improvement initiatives which draw physician's attention to pre-test probability tools which can curbing subsequent inappropriate investigations and improve patient care. Disclosures Wu: Servier: Other: advisory board; BMS-pfizer: Honoraria, Other: advisory board; leo pharma: Other: advisory board; Pfizer: Honoraria.
Récupéré en direct depuis OpenAlex et désinversé. Les résumés ne sont pas conservés dans cette base de données : les index inversés représentent 8,6 Go des 9,3 Go de texte de la base, et le serveur dispose de 13 Go libres.
Comment cette classification a été obtenuedéplier
Prédiction machine sur la base complète
Imitation des enseignantsNi prévalence calibrée, ni vérité terrain. Validation humaine à venir. Le volet Gemma est une étiquette directe du modèle pour chaque travail de la base, lue sur la notice réduite au titre. Le volet Codex est un classifieur appris des 10 348 étiquettes directes de Codex et calibré sur les taux pondérés de l'échantillon; les champs sans appui suffisant ne portent aucun appel Codex. Le mode candidate est l'union des deux volets; le consensus est leur intersection. Ces sorties portent le statut machine_predicted_unvalidated et ne sont pas des étiquettes humaines.
Scores du classifieur distillé par catégorie (deux têtes)
| Catégorie | Codex | Gemma |
|---|---|---|
| Métarecherche | 0,001 | 0,008 |
| Méta-épidémiologie (sens strict) | 0,000 | 0,000 |
| Méta-épidémiologie (sens large) | 0,000 | 0,000 |
| Bibliométrie | 0,003 | 0,003 |
| Études des sciences et des technologies | 0,000 | 0,000 |
| Communication savante | 0,001 | 0,000 |
| Science ouverte | 0,001 | 0,000 |
| Intégrité de la recherche | 0,000 | 0,000 |
| Charge utile insuffisante (le modèle a refusé de juger) | 0,001 | 0,000 |
Scores machine (provisoires)
Les deux têtes enseignantes du modèle étudiant, lues sur ce travail. Un score ordonne la base pour la relecture; il n'affirme jamais une catégorie, et le statut de validation accompagne chaque rangée tel quel.
Scores de référence d'un modèle non mature (critères de maturité non atteints, 7 itérations). Un score ordonne; il n'affirme jamais une catégorie.
score_only:v0-immature-baseline · tel quel depuis la passe de notation : score_only signifie que le nombre peut ordonner les travaux, et qu'aucune étiquette de catégorie n'en découleClassification
machine, non validéePrédiction automatique; un appel candidat d’une seule source (Gemma direct ou Codex distillé), pas un consensus.
Le détail, modèle par modèle et score par score, se trouve en fin de page sous « Comment cette classification a été obtenue ».