A Combination of D-Dimer Testing and Wells Clinical Probability Criteria Can Reduce Over-Utilization of Venous Duplex Ultrasound in a Contemporary High-Volume Hospital
Michael Yacoub, MD.,ACS.,RPVI1, Albeir Mousa, MD.,FACS.,RPVI.,MPH.,MBA2, Mike Broce3, Ali AbuRahma, MD.,FACS.,RVI2.
1WVU, Charleston, WV, USA, 2West Virginia Univeristy, Charleston, WV, USA, 3CAMC Research Institute, Charleston, WV, USA.
Objective(s): A D-Dimer (DD) level in addition to pretest probability score using Wells criteria (PCP) can safely exclude Deep Venous Thrombosis (DVT). In current study, we sought to examine the correlation between proposed DD and PCP model in approaching diagnosis and to determine the location and severity of a possible DVT in high volume hospitals. Methods Patients who presented with limb swelling +/- pain were retrospectively examined from June 2014 to July 2015. After calculating PCP, patients were divided into low, moderate, and high-risk. Electronic DD results utilizing ELISA, PCP data and Venous Duplex Ultrasound (VDU) analysis data were merged and analyzed based on receiver operator characteristic (ROC) curve to determine DD cutoff point for each PCP. Abnormal DD with average value ≥ 0.6 mg/L was correlated to positive DVT to differentiate proximal (above popliteal v.) from distal (below popliteal v.). Results: Data of 1909 patients were analyzed and 239 (12.5%) were excluded secondary to previous history of DVT. Average age 62.1 ± 16.3 years, females (55.7%) and majority presented with limb pain and edema (87%). DD was completed in 202 patients and correlate with all positive and negative DVT patients (100% sensitivity & -ve predictive value). In 26/202 DD were in the normal range 0.1-0.59 mg/L, all of which were negative for DVT (100% sensitive), 51/202 DD of 0.6-1.2 mg/L values only 3 DVTs were recorded, all of them Distal. Also, 668 Patients with PCP <1, -ve DD were sent for VDU. Thus 745 patients had unneeded VDU study, potential charge savings for VDU for all (745 × $1557 = $1,159,965), DD for all (745 × $182 = $135,595) with total potential savings of $1,024,370. Conclusions: This study suggests that D-Dimer is still underutilized and along with PCP can reduce significant number of unneeded VDU. Higher value of DD (> 1.2 mg/L) may raise concern for proximal DVT. Concern on cost-effectiveness exists and raises the demand for proposed algorithm to be followed.
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