Diagnostic Accuracy and Financial Implications of Age-Adjusted D-Dimer Strategies for the Diagnosis of Deep Venous Thrombosis in the Emergency Department |
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| Authors: | Peter M Reardon Sean Patrick Monica Taljaard Kednapa Thavorn Marie-Joe Nemnom Muhammad Mukarram Soo-Min Kim Gregoire Le Gal Longlong Huang Venkatesh Thiruganasambandamoorthy |
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| Institution: | 1. Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada;2. Department of Emergency Medicine, University of British Columbia, Vancouver, British Columbia, Canada;3. School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada;4. Ottawa Hospital Research Institute, Ottawa, Ontario, Canada;6. Institute for Clinical and Evaluative Sciences, University of Ottawa, Ottawa, Ontario, Canada;5. Division of Hematology, Department of Medicine, Thrombosis Program, University of Ottawa, Ottawa, Ontario, Canada |
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| Abstract: | BackgroundMultiple D-dimer cutoffs have been suggested for older patients to improve diagnostic specificity for venous thromboembolism. These approaches are better established for pulmonary embolism.ObjectivesWe evaluated the diagnostic performance and compared the health system cost for previously suggested cutoffs and a new D-dimer cutoff for low-risk emergency department (ED) deep venous thrombosis (DVT) patients.MethodsWe conducted a retrospective cohort study in two large EDs involving patients aged > 50 years who had low pretest probability for DVT and had a D-dimer performed. The outcome was a diagnosis of DVT at 30 days. We evaluated the diagnostic accuracy and estimated the difference in cost for cutoffs of 500 ng/mL and the age-adjusted (age × 10) rule. A derived cutoff of 1000 ng/mL was also assessed.ResultsNine hundred and seventy-two patients were included (median age 66 years; 59.5% female); 63 (6.5%) patients were diagnosed with DVT. The conventional cutoff of < 500 ng/mL demonstrated a sensitivity of 100% (95% confidence interval CI] 94.3–100%) and a specificity of 35.6% (95% CI 32.5–38.8%). The age-adjusted approach increased specificity while maintaining high sensitivity. A new cutoff of 1000 ng/mL demonstrated improved performance: sensitivity 100% (95% CI 94.3–00%) and specificity 66.3% (95% CI 63.2–69.4%). Compared to the conventional approach, both the 1000 ng/mL cutoff and the age-adjusted cutoffs could save healthcare dollars. A cutoff of 1000 ng/mL could have saved 310 ED length of stay hours and $166,909 (Canadian dollars) in our cohort, or an average savings of 0.32 h and $172 per patient.ConclusionsAmong patients aged > 50 years with suspected DVT, the age-adjusted D-dimer and a cutoff of 1000 ng/mL improved specificity without compromising sensitivity, and lowered the health care system cost compared to that for the conventional approach. |
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| Keywords: | deep venous thrombosis |
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