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Accuracy of the Wells Clinical Prediction Rule for Pulmonary Embolism in Older Ambulatory Adults
Author(s) -
Schouten Henrike J.,
Geersing GeertJan,
Oudega Ruud,
Delden Johannes J.M.,
Moons Karel G.M.,
Koek Huiberdina L.
Publication year - 2014
Publication title -
journal of the american geriatrics society
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 1.992
H-Index - 232
eISSN - 1532-5415
pISSN - 0002-8614
DOI - 10.1111/jgs.13080
Subject(s) - medicine , confidence interval , pulmonary embolism , clinical prediction rule , ambulatory , prospective cohort study , cohort , pediatrics
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. Participants Older adults (≥60) clinically suspected of having a PE (N = 294, mean age 76, 44% residing in a nursing home). Measurements The presence of PE was confirmed using a composite reference standard including computed tomography and 3‐month follow‐up. The proportion of individuals with an unlikely risk of PE was calculated according to the Wells rule (≤4 points) plus a normal qualitative point‐of‐care D‐dimer test (efficiency) and the presence of symptomatic PE during 3 months of follow‐up within these patients (failure rate). Results Pulmonary embolism occurred in 83 participants (28%). Eighty‐five participants had an unlikely risk according to the Wells rule and a normal D‐dimer test (efficiency 29%), five of whom experienced a nonfatal PE during 3 months of follow‐up (failure rate = 5.9%, 95% confidence interval ( CI ) = 2.5–13%). According to a refitted diagnostic strategy for older adults, 69 had a low risk of PE (24%), two of whom had PE (failure rate = 2.9%, 95% CI = 0.8–10%). Conclusion The use of the well‐known and widely used Wells rule (original or refitted) does not guarantee safe exclusion of PE in older unhospitalized adults with suspected PE . This may lead to discussion among professionals as to whether the original or revised Wells rule is useful for elderly outpatients.