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

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. 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.

Accuracy of the general practitioner’s sense of alarm when confronted with dyspnoea and/or chest pain: a prospective observational study

“…Several studies were about the predictive value of gut feelings in the area of serious infection in children29; sepsis in primary care30; children with respiratory tract infection in general practice31; use of gestalt with regard to 32PE and the role of intuition in the suspicion of cancer 33 34. All these studies used a binary question ‘do you have gut feelings?’29–31 without using a proper definition of the concept.…”

Diagnostic Performance of Emergency Physician Gestalt for Predicting Acute Appendicitis in Patients Age 5 to 20 Years

“…For example, the presence of RLQ maximal tenderness was dramatically higher in the 90% to 100% gestalt category compared with the 1% to 10% gestalt category (p < 0.001), while pain <24 hours was not significantly associated with increased gestalt (p = 0.99). Performance of physician gestalt is known to vary in a condition‐specific manner, and it is possible that pediatric appendicitis is associated with better performance due to the presence of trademark physical examination findings such as RLQ tenderness . Interestingly, 57.6% of patients in the lowest gestalt subgroup had pain <24 hours, accounting for 81% of appendicitis cases in the low‐gestalt cohort.…”

“…Physician gestalt can be defined as a physician’s implicit probability estimation based on a synthesis of provider experience and clinical perception in the absence of definitive diagnostic testing . Assessments of physician gestalt across various medical conditions, such as pulmonary embolism and acute coronary syndrome, demonstrate variable accuracy; for some conditions, such as pulmonary embolism, studies suggest that gestalt can perform similarly to clinical prediction rules . However, physician gestalt of diagnostic probability is rarely incorporated into risk‐stratification tools.…”

Is the Diagnosis of Pulmonary Embolism Using Scoring Systems Still a Dilemma?: A Case Report

“…The probability of PE was 2% when these results were evaluated together with D-dimer negativity (4). A study comparing clinical perception and Wells scoring combined with the qualitative D-dimer measurement showed that both low-probability rating in Wells and clinical perception could be used confidently for PE exclusion (8). When the rGeneva score was compared with the Wells score, the latter was found to be better in assessing the high probability of PE (9).…”