Is D-dimer used according to clinical algorithms in the diagnostic work-up of patients with suspicion of venous thromboembolism? A study in six European countries

Kristoffersen, Ann Helen; Ajzner, Éva; Rogić, Dunja; Sözmen, Eser Yıldırım; Carraro, Paolo; Faria, Ana Paula; Watine, Joseph; Meijer, Piet; Sandberg, Sverre

doi:10.1016/j.thromres.2016.04.001

Cited by 20 publications

(14 citation statements)

References 29 publications

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“…Because the clinical pre‐test probabilities of VTE were not defined, the NPVs/PPVs and efficiencies calculated in this study can only be applied to a VTE population with both high and low clinical suspicions. This does not accord with the recommended diagnostic algorithm, but nevertheless is not uncommon in clinical practice . It was recently suggested that D‐dimer (< 0.75 mg L −1 FEU) could be used without previous assessment of clinical pre‐test possibility to exclude PE ; however, this could not be verified in a meta‐analysis .…”

Section: Discussionmentioning

confidence: 92%

Age‐adjusted D‐dimer cut‐off leads to more efficient diagnosis of venous thromboembolism in the emergency department: a comparison of four assays

Farm

Siddiqui

Onelöv

et al. 2018

Journal of Thrombosis and Haemostasis

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Background The study compares different D-dimer assays and age-adjusted cut-offs in outpatients with suspected venous thromboembolism (VTE). The plasma concentration of this sensitive biomarker is increased by activated coagulation, but also by several conditions that are linked to an increased risk of VTE. One such condition is old age, which poses a common clinical problem where many prefer not to analyze D-dimer in elderly patients. Age-adjusted cut-offs have been validated for both deep venous thrombosis (DVT) and pulmonary embolism, aiming to increase specificity without notably decreasing sensitivity. Objectives We evaluated four common D-dimer assays in parallel, with and without applying age-adjusted cut offs for VTE. Patients/methods The prospective single-center study was conducted in 940 outpatients attending the emergency department with clinically suspected pulmonary embolism or DVT. Four automated D-dimer assays were compared (Siemens INNOVANCE , Roche Tina-quant, Medirox MRX and STA -Liatest D-Di PLUS). Results All assays performed with areas under the ROC curve (AUC) > 0.9 and maintained their sensitivities after implementation of age-adjusted cut-offs. Specificities increased by 6-7% and number needed to test decreased by < 0.3. The rate of false positive results decreased by 6% overall and by 10-20% for patients ≥ 70. Conclusions Age-adjusted cut-offs resulted in maintained high sensitivity and a modest improvement in specificity and number needed to test for all evaluated D-dimer assays. There was a significant reduction in false positive results, which reflects avoidable unnecessary imaging without any compromise of clinical safety. This suggests a potential to benefit the management of VTE in elderly patients, both clinically and economically.

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Section: Discussionmentioning

confidence: 92%

Age‐adjusted D‐dimer cut‐off leads to more efficient diagnosis of venous thromboembolism in the emergency department: a comparison of four assays

Farm

Siddiqui

Onelöv

et al. 2018

Journal of Thrombosis and Haemostasis

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“…A good CPR should not contain subjective variables, and it should be accurate, reproducible, easy to remember, and offer a standardized approach compared to clinical assessment (especially for inexperienced physicians) [1,155]. However, pretest probability calculation may still be subjective [181,182]. These algorithms are considered clinically validated when the number of thromboembolic event after 3 months is as high as 1-2% compared to a gold standard test (pulmonary angiography for PE and venography for DVT) [183].…”

Section: Clinical Prediction Rules (Cpr)mentioning

confidence: 99%

D-dimer: Preanalytical, analytical, postanalytical variables, and clinical applications

Favresse

Lippi

Roy

et al. 2018

Critical Reviews in Clinical Laboratory Sciences

149

103

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D-dimer is a soluble fibrin degradation product deriving from the plasmin-mediated degradation of cross-linked fibrin. D-dimer can hence be considered a biomarker of activation of coagulation and fibrinolysis, and it is routinely used for ruling out venous thromboembolism (VTE). D-dimer is increasingly used to assess the risk of VTE recurrence and to help define the optimal duration of anticoagulation treatment in patients with VTE, for diagnosing disseminated intravascular coagulation, and for screening medical patients at increased risk of VTE. This review is aimed at (1) revising the definition of D-dimer; (2) discussing preanalytical variables affecting the measurement of D-dimer; (3) reviewing and comparing assay performance and some postanalytical variables (e.g. different units and age-adjusted cutoffs); and (4) discussing the use of D-dimer measurement across different clinical settings.

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“…Ordering a D-dimer test in patients with suspected venous thromboembolism, for example, is only recommended when the clinic pretest probability is low [48]. Kristoffersen et al showed that this recommendation is frequently overlooked [49]. Another example is the 4T-score used for ruling out type 2 heparininduced thrombocytopenia (HIT2) [50].…”

Section: B Other Gate-keeping Strategiesmentioning

confidence: 99%

Managing inappropriate utilization of laboratory resources

et al. 2018

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Background The inappropriate use of laboratory resources, due to excessive number of tests not really necessary for patient care or by failure to order the appropriate diagnostic test, may lead to wrong, missed or delayed diagnosis, thus potentially jeopardizing patient safety. It is estimated that 5-95% of tests are currently used inappropriately, depending on the appropriateness criteria, thus significantly contributing to the potential of generating medical errors, the third leading cause of death in the US. Content In this review, we discuss the reasons as well as the medical and financial consequences of inappropriate utilization of laboratory tests. We then provide demand management (DM) tools as a means for overcoming this issue and also discuss their benefits, challenges, limitations and requirements for successful implementation. Summary and outlook When based on current evidence, adapted to local conditions and developed in close collaboration with clinicians, DM is a reasonable strategy for progressing toward better management of over- and underuse of laboratory resources.

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Is D-dimer used according to clinical algorithms in the diagnostic work-up of patients with suspicion of venous thromboembolism? A study in six European countries

Cited by 20 publications

References 29 publications

Age‐adjusted D‐dimer cut‐off leads to more efficient diagnosis of venous thromboembolism in the emergency department: a comparison of four assays

Age‐adjusted D‐dimer cut‐off leads to more efficient diagnosis of venous thromboembolism in the emergency department: a comparison of four assays

D-dimer: Preanalytical, analytical, postanalytical variables, and clinical applications

Managing inappropriate utilization of laboratory resources

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