Browsing by Author "Sozmen, Eser Y."
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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 countriesPublication . Kristoffersen, Ann Helen; Ajzner, Eva; Rogic, Dunja; Sozmen, Eser Y.; Carraro, Paolo; Faria, Ana Paula; Watine, Joseph; Meijer, Piet; Sandberg, Sverre; joint Working Group on Postanalytical Phase (WG-POST) of the European Federation of Clinical Chemistry and Laboratory Medicine (EFLM) and European Organisation for External Quality Assurance Providers in Laboratory Medicine (EQALM).Introduction: Clinical algorithms consisting of pre-test probability estimation and D-dimer testing are recommended in diagnostic work-up for suspected venous thromboembolism (VTE). The aim of this study was to explore how physicians working in emergency departments investigated patients suspected to have VTE. Materials and methods: A questionnaire with two case histories related to the diagnosis of suspected pulmonary embolism (PE) (Case A) and deep venous thrombosis (DVT) (Case B) were sent to physicians in six European countries. The physicians were asked to estimate pre-test probability of VTE, and indicate their clinical actions. Results: In total, 487 physicians were included. Sixty percent assessed pre-test probability of PE to be high in Case A, but 7% would still request only D-dimer and 11% would exclude PE if D-dimer was negative, which could be hazardous. Besides imaging, a D-dimer test was requested by 41%, which is a “waste of resources” (extra costs and efforts, no clinical benefit). For Case B, 92% assessed pre-test probability of DVT to be low. Correctly, only D-dimer was requested by 66% of the physicians, while 26% requested imaging, alone or in addition to D-dimer, which is a “waste of resources”. Conclusions: These results should encourage scientific societies to improve the dissemination and knowledge of the current recommendations for the diagnosis of VTE.
- Pre- and post-test probabilities of venous thromboembolism and diagnostic accuracy of D-dimer, estimated by European clinicians working in emergency departmentsPublication . Kristoffersen, Ann Helen; Ajzner, Eva; Bauça, Josep Miquel; Carraro, Paolo; Faria, Ana Paula; Hillarp, Andreas; Rogic, Dunja; Sozmen, Eser Y.; Watine, Joseph; Meijer, Piet; Sandberg, SverreIntroduction: In patients with suspected venous thromboembolism (VTE), it is recommended to estimate the pre-test probability of VTE, either by experience or by standardized scoring schemes (e.g. Wells or Geneva score), before performing a D-dimer test. Patients with a low probability or unlikely VTE should have D-dimer performed, and if negative, VTE can be excluded, without further investigations, while if positive, the patient should be referred to radiologic imaging to confirm or exclude VTE. Patients with a high pre-test probability or likely VTE should be referred directly to radiologic imaging without D-dimer testing. Thus, to estimate the pre-test probability of VTE before D-dimer testing is of uttermost importance since the diagnostic algorithm and the interpretation of the D-dimer result is dependent upon this. Further, the diagnostic accuracy of D-dimer can be expressed by the likelihood ratio (LR). LR is the ratio between the probability of a test result given that VTE is present, and probability of the same test result if VTE is absent. A LR of< 1 decreases the probability of disease and a LR of> 1 increases the probability of disease. When clinicians estimate the pre-test probability for VTE, the post-test probability (after D-dimer testing) can be calculated using the LR for D-dimer either for a positive or negative test (i.e. D-dimer above or below the cut-off level, respectively). Probably, most clinicians do not know the LR for D-dimer, but it is indirectly implemented in the above mentioned algorithm for investigating a patient with suspected VTE. The advice to rule out VTE in a patient if the pre-test probability of VTE is low and the D-dimer is below the cut-off level reflects that the post-test probability of VTE in this case is sufficiently low to rule out VTE (should be< 1-2%). However, if the pre-test probability of VTE is high or likely, a negative D-dimer cannot decrease the post-test probability enough to rule out VTE (the post-test probability will still be about 10%) [4,5]. Therefore, only imaging should be requested when pre-test probability of VTE is high. A positive D-dimer cannot increase post-test probability of VTE enough to confirm VTE diagnosis in any case, since D-dimer is a non-specific VTE marker and levels can be increased in several other clinical situations (e.g. infection, inflammation, cancer and pregnancy). The aims of this survey were 1) to study the relationship between pre-test probabilities estimated by clinicians using two case histories and how the same clinicians' categorized the patients into low, moderate or high probability of VTE or into unlikely or likely VTE, and 2) to examine the clinicians' perception of diagnostic accuracy of D-dimer by calculating the LRs based upon their estimated pre- and post-test probabilities.