Usefulness of clinical prediction rules for the diagnosis of venous thromboembolism: A systematic review
Received 21 October 2003; received in revised form 15 April 2004; accepted 15 April 2004.
Purpose
To summarize the evidence on the predictive value of clinical prediction rules for the diagnosis of venous thromboembolism.
Methods
We selected all studies in the English literature in which a clinical prediction rule was prospectively validated against a reference standard, and calculated likelihood ratios, predictive values, and the area under the receiver operating characteristic (ROC) curve for each prediction rule.
Results
Twenty-three studies met our eligibility criteria: 17 evaluated prediction rules for the diagnosis of deep venous thrombosis and six evaluated rules for pulmonary embolism. The most frequently evaluated prediction rule for deep vein thrombosis was the Wells rule, which had median positive likelihood ratios of 6.62 for patients with a high pretest probability, 1 for moderate pretest probability, and 0.22 for low pretest probability. The median area under the ROC curve was 0.82. Addition of the D-dimer test to the prediction rule increased the median area under the curve to 0.90. The Wells prediction rule was the most commonly studied for pulmonary embolus and had median positive likelihood ratios of 6.75 for those with high pretest probability, 1.82 for moderate pretest probability, and 0.13 for low pretest probability. The median area under the ROC curve was 0.82.
Conclusion
The Wells prediction rule is useful in identifying patients at low risk of being diagnosed with venous thromboembolism. The addition of a rapid latex D-dimer assay improved the overall performance of the prediction rule.
aDepartment of Medicine (LJT, JBS, JAK, DTB, MBS, MWJ, EBB)
bRussell H. Morgan Department of Radiology and Radiological Science (JE), Johns Hopkins University School of Medicine, Baltimore, Maryland
cDepartments of Epidemiology and Health Policy and Management (EBB), Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland
Requests for reprints should be addressed to Leonardo J. Tamariz, MD, MPH, Veterans Affairs Medical Center, 1201 NW 16th Street, Room B1039, Miami, Florida 33125
This study was conducted by the Johns Hopkins Evidence-Based Practice Center through Contract No. 290-97-0006 from the Agency for Healthcare Research and Quality, Rockville, Maryland. Dr. Tamariz is supported by a training grant (T32HL07180) in behavioral research in heart and vascular diseases from the National Heart Lung and Blood Institute. The authors are responsible for the content of this article, including any treatment recommendations. No statement in this article should be construed as an official position of the Agency for Healthcare Research and Quality or the U.S. Department of Health and Human Services.
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