title: Safe exclusion of pulmonary embolism using the Wells rule and qualitative D-dimer testing in primary care: prospective cohort study.
abstract: OBJECTIVE
  To validate the use of the Wells clinical decision rule combined with a point of care D-dimer test to safely exclude pulmonary embolism in primary care.
  
  
  METHODS
  Prospective cohort study.
  
  
  METHODS
  Primary care across three different regions of the Netherlands (Amsterdam, Maastricht, and Utrecht).
  
  
  METHODS
  598 adults with suspected pulmonary embolism in primary care.
  
  
  METHODS
  Doctors scored patients according to the seven variables of the Wells rule and carried out a qualitative point of care D-dimer test. All patients were referred to secondary care and diagnosed according to local protocols. Pulmonary embolism was confirmed or refuted on the basis of a composite reference standard, including spiral computed tomography and three months' follow-up.
  
  
  METHODS
  Diagnostic accuracy (sensitivity and specificity), proportion of patients at low risk (efficiency), number of missed patients with pulmonary embolism in low risk category (false negative rate), and the presence of symptomatic venous thromboembolism, based on the composite reference standard, including events during the follow-up period of three months.
  
  
  RESULTS
  Pulmonary embolism was present in 73 patients (prevalence 12.2%). On the basis of a threshold Wells score of ≤ 4 and a negative qualitative D-dimer test result, 272 of 598 patients were classified as low risk (efficiency 45.5%). Four cases of pulmonary embolism were observed in these 272 patients (false negative rate 1.5%, 95% confidence interval 0.4% to 3.7%). The sensitivity and specificity of this combined diagnostic approach was 94.5% (86.6% to 98.5%) and 51.0% (46.7% to 55.4%), respectively.
  
  
  CONCLUSIONS
  A Wells score of ≤ 4 combined with a negative qualitative D-dimer test result can safely and efficiently exclude pulmonary embolism in primary care.
authors.affiliation: Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Universiteitsweg 100, 3584 CG Utrecht, Netherlands. g.j.geersing@umcutrecht.nl
authors.forename: Geert-Jan
authors.initials: GJ
authors.lastname: Geersing
authors.forename: Petra M G
authors.initials: PM
authors.lastname: Erkens
authors.forename: Wim A M
authors.initials: WA
authors.lastname: Lucassen
authors.forename: Harry R
authors.initials: HR
authors.lastname: Büller
authors.forename: Hugo Ten
authors.initials: HT
authors.lastname: Cate
authors.forename: Arno W
authors.initials: AW
authors.lastname: Hoes
authors.forename: Karel G M
authors.initials: KG
authors.lastname: Moons
authors.forename: Martin H
authors.initials: MH
authors.lastname: Prins
authors.forename: Ruud
authors.initials: R
authors.lastname: Oudega
authors.forename: Henk C P M
authors.initials: HC
authors.lastname: van Weert
authors.forename: Henri E J H
authors.initials: HE
authors.lastname: Stoffers
mesh_terms: D000328:Adult; D000368:Aged; D000933:Antifibrinolytic Agents / Q000378:metabolism; D015415:Biomarkers / Q000097:blood; D003937:Diagnosis, Differential; D005260:Female; D005338:Fibrin Fibrinogen Degradation Products / Q000378:metabolism*; D006801:Humans; D008297:Male; D008875:Middle Aged; D009426:Netherlands / Q000453:epidemiology; D011237:Predictive Value of Tests; D011320:Primary Health Care / Q000592:standards*; D011446:Prospective Studies; D011655:Pulmonary Embolism / Q000097:blood* / Q000175:diagnosis* / Q000453:epidemiology; D012680:Sensitivity and Specificity
chemical_list: D000933:Antifibrinolytic Agents; D015415:Biomarkers; D005338:Fibrin Fibrinogen Degradation Products; C036309:fibrin fragment D