Alternative diagnosis other than pulmonary embolism as a subjective variable in the Wells clinical decision rule: not so bad after all

Klok, Frederikus A.; Djurabi, R. Karami; Nijkeuter, Mathilde; Huisman, Menno V.

doi:10.1111/j.1538-7836.2007.02475.x

Cited by 20 publications

(16 citation statements)

References 6 publications

(5 reference statements)

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“…We found that 97% of the cases in which individual patients were classified differently could be explained by this subjective item. Although implicit clinical judgement may improve the accuracy of a prediction rule, as was shown using the original Geneva score [9], and the important weight and high predictive value of the subjective item of the Wells rule in comparison with its other items [10], the Wells rule did not perform better than the completely objective revised Geneva score.…”

Section: Discussionmentioning

confidence: 99%

Comparison of the revised Geneva score with the Wells rule for assessing clinical probability of pulmonary embolism

Klok

Kruisman

Spaan

et al. 2008

Journal of Thrombosis and Haemostasis

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137

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Summary. Background: The revised Geneva score, a standardized clinical decision rule in the diagnosis of pulmonary embolism (PE), was recently developed. The Wells clinical decision is widely used but lacks full standardization, as it includes subjective clinicianÕs judgement. We have compared the performance of the revised Geneva score with the Wells rule, and their usefulness for ruling out PE in combination with Ddimer measurement. Methods: In 300 consecutive patients, the clinical probability of PE was assessed prospectively by the Wells rule and retrospectively using the revised Geneva score. Patients comprised a random sample from a single center, participating in a large prospective multicenter diagnostic study. The predictive accuracy of both scores was compared by area under the curve (AUC) of receiver operating characteristic (ROC) curves. Results: The overall prevalence of PE was 16%. The prevalence of PE in the low-probability, intermediateprobability and high-probability categories as classified by the revised Geneva score was similar to that of the original derivation set. The performance of the revised Geneva score as measured by the AUC in a ROC analysis did not differ statistically from the Wells rule. After 3 months of follow-up, no patient classified into the low or intermediate clinical probability category by the revised Geneva score and a normal D-dimer result was subsequently diagnosed with acute venous thromboembolism. Conclusions: This study suggests that the performance of the revised Geneva score is equivalent to that of the Wells rule. In addition, it seems safe to exclude PE in patients by the combination of a low or intermediate clinical probability by the revised Geneva score and a normal D-dimer level. Prospective clinical outcome studies are needed to confirm this latter finding.

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Section: Discussionmentioning

confidence: 99%

Comparison of the revised Geneva score with the Wells rule for assessing clinical probability of pulmonary embolism

Klok

Kruisman

Spaan

et al. 2008

Journal of Thrombosis and Haemostasis

Self Cite

137

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“…17 It could therefore be argued that gestalt and this subjective item of the Wells rule more or less capture the same information. The Wells rule combines this information with other diagnostic variables; hence, it may be expected to give better predictions when compared with only the gestalt information.…”

Section: Strengths and Limitationsmentioning

confidence: 99%

Ruling Out Pulmonary Embolism in Primary Care: Comparison of the Diagnostic Performance of "Gestalt" and the Wells Rule

Hendriksen

Lucassen

Erkens

et al. 2016

The Annals of Family Medicine

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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. METHODSFamily 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.

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“…16 Dit subjectieve item bevat voor een deel dezelfde informatie als die welke in de klinische blik gebruikt wordt. De uitkomsten van de Wellsbeslisregel zijn mogelijk gunstiger doordat de regel deze informatie combineert met andere diagnostische variabelen.…”

Section: Resultatenunclassified

Klinische blik versus beslisregel bij longembolie

Hendriksen¹,

Lucassen²,

Erkens³

et al. 2017

Huisarts Wet

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, et al. richtlijnen voor huisartsen adviseren dan ook een vorm van risicostratificatie toe te passen om te bepalen bij welke patienten het risico op een longembolie zodanig laag is dat verwijzing en aanvullend onderzoek veilig achterwege kunnen blijven. 2,3 Er bestaan formele diagnostische predictiemodellen, zoals de Wells-beslisregel in combinatie met een kwalitatieve sneltest om de aanwezigheid van D-dimeer vast te stellen, maar de huisarts kan ook uitgaan van de eigen 'klinische blik'. [4][5][6][7][8] In het algemeen beschouwt men beslisregels als accurater, Wat is nieuw?▪ De Wells-beslisregel om een longembolie uit te sluiten is even veilig als de klinische blik van de huisarts.▪ Op basis van hun klinische blik verwijzen huisartsen 75% van de patiënten met een mogelijke longembolie voor aanvullende diagnostiek, op basis van de Wells-beslisregel is dat 55%.▪ Een beslisregel is niet veiliger of onveiliger dan de klinische blik, maar wel aanzienlijk efficiënter en kan daardoor overdiagnostiek, overbehandeling en onnodige zorgconsumptie beperken.

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Alternative diagnosis other than pulmonary embolism as a subjective variable in the Wells clinical decision rule: not so bad after all

Cited by 20 publications

References 6 publications

Comparison of the revised Geneva score with the Wells rule for assessing clinical probability of pulmonary embolism

Comparison of the revised Geneva score with the Wells rule for assessing clinical probability of pulmonary embolism

Ruling Out Pulmonary Embolism in Primary Care: Comparison of the Diagnostic Performance of "Gestalt" and the Wells Rule

Klinische blik versus beslisregel bij longembolie

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