Are the latest point-of-care D-dimer devices ready for use in general practice? A prospective clinical evaluation of five test systems with a capillary blood feature for suspected venous thromboembolism.

Introduction: We evaluated clinical performance of five novel point-of-care (POC) D-dimer devices with a capillary finger stick feature for predicting venous thromboembolism (VTE) in general practice: Exdia TRF Plus (E), AFIAS-1® (A), Standard F200® (S), LumiraDx™ (L) and Hipro AFS/1® (H).

Materials And Methods: Primary care patients with a low suspicion of a VTE were asked to consent to (i) draw additional venous blood samples, (ii) perform a capillary POC D-dimer test, (iii) approach their general practitioner afterwards for clinical outcomes. Venous plasma samples were processed on all POC devices and a laboratory-based assay (STA-Liatest®D-Di PLUS assay).

Clinical decision rules in primary care: necessary investments for sustainable healthcare.

Clinical judgement in primary care is more often decisive than in the hospital. Clinical decision rules (CDRs) can help general practitioners facilitating the work-through of differentials that follows an initial suspicion, resulting in a concrete 'course of action': a 'rule-out' without further testing, a need for further testing, or a specific treatment. However, in daily primary care, the use of CDRs is limited to only a few isolated rules.

Two point-of-care test-based approaches for the exclusion of deep vein thrombosis in general practice: a cost-effectiveness analysis.

Background: In the diagnostic work-up of deep vein thrombosis (DVT), the use of point-of-care-test (POCT) D-dimer assays is emerging as a promising patient-friendly alternative to regular D-dimer assays, but their cost-effectiveness is unknown. We compared the cost-effectiveness of two POCT-based approaches to the most common, laboratory-based, situation.

Methods: A patient-level simulation model was developed to simulate the diagnostic trajectory of patients presenting with symptoms of DVT at the general practitioner (GP).

Performance of C-Reactive Protein, Procalcitonin, TAT Complex, and Factor VIII in Addition to D-Dimer in the Exclusion of Venous Thromboembolism in Primary Care Patients.

Background: In primary care, D-dimer-combined with a clinical assessment-is recommended for ruling-out venous thromboembolism (VTE). However, D-dimer testing frequently yields false-positive results, notably in the elderly, and the search for novel biomarkers thus continues. We assessed the added diagnostic value of 4 promising laboratory tests.

Real-life impact of clinical prediction rules for venous thromboembolism in primary care: a cross-sectional cohort study.

Objective: Clinical prediction rules (CPRs) followed by D-dimer testing were shown to safely rule out venous thromboembolism (VTE) in about half of all suspected patients in controlled and experienced study settings. Yet, its real-life impact in primary care is unknown. The aim of this study was to determine the real-life impact of CPRs for suspected VTE in primary care.

Effect of tailoring anticoagulant treatment duration by applying a recurrence risk prediction model in patients with venous thromboembolism compared to usual care: A randomized controlled trial.

Background: Patients with unprovoked (i.e., without the presence of apparent transient risk factors such as recent surgery) venous thromboembolism (VTE) are at risk of recurrence if anticoagulants are stopped after 3-6 months, yet their risk remains heterogeneous.

Analytical performance and user-friendliness of five novel point-of-care D-dimer assays.

D-dimer testing combined with a clinical assessment has become a standard pathway for ruling-out venous thromboembolism (VTE). Recently, novel Point-of-Care (POC) D-dimer assays have been introduced, enabling low-volume blood sampling for rapid exclusion of VTE in a one-step procedure. We assessed the analytical validity and user-friendliness of a set of these novel POC D-dimer assays, and compared the results with a standard laboratory assay.

Integrated management of atrial fibrillation in primary care: results of the ALL-IN cluster randomized trial.

Aims: To evaluate whether integrated care for atrial fibrillation (AF) can be safely orchestrated in primary care.

Methods And Results: The ALL-IN trial was a cluster randomized, open-label, pragmatic non-inferiority trial performed in primary care practices in the Netherlands. We randomized 26 practices: 15 to the integrated care intervention and 11 to usual care.

Effectiveness of CHADS-VASc based decision support on stroke prevention in atrial fibrillation: A cluster randomised trial in general practice.

Background: Guidelines on atrial fibrillation (AF) recommend the CHADS-VASc rule for anticoagulant decision-making, but underuse exists. We studied the impact of an automated decision support on stroke prevention in patients with AF in a cluster randomised trial in general practice.

Methods: Intervention practices were provided with a CHADS-VASc based anticoagulant treatment recommendation.

Integrated management of atrial fibrillation including tailoring of anticoagulation in primary care: study design of the ALL-IN cluster randomised trial.

Introduction: In our ageing society, we are at the merge of an expected epidemic of atrial fibrillation (AF). AF management requires an integrated approach, including rate or rhythm control, stroke prevention with anticoagulation and treatment of comorbidities such as heart failure or type 2 diabetes. As such, primary care seems to be the logical healthcare setting for the chronic management of patients with AF.

Clinical characteristics associated with diagnostic delay of pulmonary embolism in primary care: a retrospective observational study.

Objectives: To evaluate the extent of delay in the diagnosis of pulmonary embolism (PE) in primary care, and to identify determinants that are associated with such diagnostic delay.

Design: Retrospective observational study.

Setting: 6 primary care practices across the Netherlands.

Multi-faceted implementation strategy to increase use of a clinical guideline for the diagnosis of deep venous thrombosis in primary care.

Background: A clinical decision rule (CDR), combined with a negative D-dimer test, can safely rule out deep venous thrombosis (DVT) in primary care. This strategy is recommended by guidelines, yet uptake by GPs is low.

Objective: To evaluate a multi-faceted implementation strategy aimed at increased use of the guideline recommended CDR plus D-dimer test in primary care patients with suspected DVT.

Clinical evaluation of eight different D-dimer tests for the exclusion of deep venous thrombosis in primary care patients.

D-dimer tests are an essential element in the diagnostic work-up of deep venous thrombosis (DVT). However, the poor standardization amongst assays necessitates clinical validation before implementation in daily practice. We therefore evaluated the analytical and diagnostic performance of eight D-dimer tests in a representative group of 290 prospectively identified consecutive primary care patients with suspected DVT.

The cost-effectiveness of point-of-care D-dimer tests compared with a laboratory test to rule out deep venous thrombosis in primary care.

Objective: Point-of-care (POC) D-dimer tests have been developed to exclude deep venous thrombosis quickly and on the spot, but are known to have lower sensitivity compared with laboratory-based tests. Their cost-effectiveness is still unknown.

Methods: We updated and extended a previously published Markov model to assess the cost-effectiveness of POC D-dimer tests ('Simplify', 'Cardiac', 'Triage' and 'Nycocard') compared with a laboratory-based latex assay to diagnose deep venous thrombosis in primary care.

Accuracy of the Wells clinical prediction rule for pulmonary embolism in older ambulatory adults.

Objectives: To determine whether the Wells clinical prediction rule for pulmonary embolism (PE), which produces a point score based on clinical features and the likelihood of diagnoses other than PE, combined with normal D-dimer testing can be used to exclude PE in older unhospitalized adults.

Design: Prospective cohort study.

Setting: Primary care and nursing homes.

Validation of the Oudega diagnostic decision rule for diagnosing deep vein thrombosis in frail older out-of-hospital patients.

Objective: We aimed to validate the Oudega diagnostic decision rule-which was developed and validated among younger aged primary care patients-to rule-out deep vein thrombosis (DVT) in frail older outpatients.

Methods: In older patients (>60 years, either community dwelling or residing in nursing homes) with clinically suspected DVT, physicians recorded the score on the Oudega rule and d-dimer test. DVT was confirmed with a composite reference standard including ultrasonography examination and 3-month follow-up.

Alternative diagnoses in patients in whom the GP considered the diagnosis of pulmonary embolism.

Introduction: Pulmonary embolism (PE) often presents with nonspecific symptoms and may be an easily missed diagnosis. When the differential diagnosis includes PE, an empirical list of frequently occurring alternative diagnoses could support the GP in diagnostic decision making.

Objectives: To identify common alternative diagnoses in patients in whom the GP suspected PE but in whom PE could be ruled out.

Exclusion of deep vein thrombosis using the Wells rule in clinically important subgroups: individual patient data meta-analysis.

Objective: To assess the accuracy of the Wells rule for excluding deep vein thrombosis and whether this accuracy applies to different subgroups of patients.

Design: Meta-analysis of individual patient data.

Data Sources: Authors of 13 studies (n = 10,002) provided their datasets, and these individual patient data were merged into one dataset.

Decisions to withhold diagnostic investigations in nursing home patients with a clinical suspicion of venous thromboembolism.

Background: This study aimed to gather insights in physicians' considerations for decisions to either refer for- or to withhold additional diagnostic investigations in nursing home patients with a suspicion of venous thromboembolism.

Methods: Our study was nested in an observational study on diagnostic strategies for suspected venous thromboembolism in nursing home patients. Patient characteristics, bleeding-complications and mortality were related to the decision to withhold investigations.

Need for tailored strategies to diagnose venous thrombo-embolism in older primary care patients. Extension of a keynote presentation at the 2012 Wonca Europe conference.

Venous thrombo-embolism (VTE, pulmonary embolism and deep vein thrombosis) is common in the elderly and short-term mortality risk increases with age. Hence, notably in older patients, accurately diagnosing VTE can be lifesaving. However, most clinically suspected individuals turn out to have no VTE after imaging examination.

Safe exclusion of pulmonary embolism using the Wells rule and qualitative D-dimer testing in primary care: prospective cohort study.

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.

Design: Prospective cohort study.

Setting: Primary care across three different regions of the Netherlands (Amsterdam, Maastricht, and Utrecht).

Non-diagnosis decisions and non-treatment decisions in elderly patients with cardiovascular diseases, do they differ?--A systematic review.

The growth in the number of possible medical interventions in the past decennia necessitates physicians to consider whether to use them. Contrary to decisions to withhold treatment, little is known about "non-diagnosis decisions" (NDD) although their consequences seem to be more uncertain. Hence, we hypothesized that "determinants" and "reasons" for NDD are different from those that are associated with non-treatment decisions (NTD).