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Multicenter Study
. 2019 May 28;9(5):e026846.
doi: 10.1136/bmjopen-2018-026846.

General practitioner use of D-dimer in suspected venous thromboembolism: historical cohort study in one geographical region in the Netherlands

Affiliations
Multicenter Study

General practitioner use of D-dimer in suspected venous thromboembolism: historical cohort study in one geographical region in the Netherlands

Angel M R Schols et al. BMJ Open. .

Abstract

Objectives: To investigate how many general practitioner (GP)-referred venous thromboembolic events (VTEs) are diagnosed during 1 year in one geographical region and to investigate the (urgent) referral pathway of VTE diagnoses, including the role of laboratory D-dimer testing.

Design: Historical cohort study.

Setting: GP patients of 47 general practices in a demarcated geographical region of 161 503 inhabitants in the Netherlands.

Participants: We analysed all 895 primary care patients in whom either the GP determined a D-dimer value or who had a diagnostic work-up for suspected VTE in a non-academic hospital during 2015.

Primary and secondary outcome measures: The primary outcomes of this study were the total number of VTEs per year and the diagnostic pathways-including the role of GP determined D-dimer testing-of patients urgently referred to secondary care for suspected VTE. Additionally, we explored the use of an age-adjusted D-dimer cut-off.

Results: The annual VTE incidence was 0.9 per 1000 inhabitants. GPs annually ordered 5.1 D-dimer tests per 1000 inhabitants. Of 470 urgently GP-referred patients, 31.3% had a VTE. Of those urgently referred based on clinical assessment only (without D-dimer testing), 73.8% (96/130) had a VTE; based on clinical assessment and laboratory D-dimer testing yielded 15.0% (51/340) VTE. Applying age-adjusted D-dimer cut-offs to all patients aged 50 years or older resulted in a reduction of positive D-dimer results from 97.9% to 79.4%, without missing any VTE.

Conclusions: Although D-dimer testing contributes to the diagnostic work-up of VTE, GPs have a high detection rate for VTE in patients who they urgently refer to secondary care based on clinical assessment only.

Keywords: epidemiology; general medicine (see internal medicine); primary care; thromboembolism.

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Conflict of interest statement

Competing interests: None declared.

Figures

Figure 1
Figure 1
Patient flow and GP use of D-dimer test. In this figure only one D-dimer test and one clinical event per patient is shown. When more than one D-dimer test was performed or more than one diagnosis-treatment code was assigned in referred patients, we evaluated the clinically most relevant event, with the highest suspicion of a PE or DVT. DVT, deep vein thrombosis; GP, general practitioner; PE, pulmonary embolism.

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