Steve Goodacre, MB, ChB, FFAEM, MSc, PhD; Alex J. Sutton, BSc, MSc, PhD; Fiona C. Sampson, BA, MSc
Goodacre S, Sutton AJ, Sampson FC. Meta-Analysis: The Value of Clinical Assessment in the Diagnosis of Deep Venous Thrombosis. Ann Intern Med. 2005;143:129-139. doi: 10.7326/0003-4819-143-2-200507190-00012
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Published: Ann Intern Med. 2005;143(2):129-139.
Clinical assessment of suspected deep venous thrombosis (DVT) should be based on systematically evaluated evidence.
To determine whether clinical findings, risk scores, and physicians' empirical judgments affect the likelihood of detecting DVT on definitive testing.
MEDLINE, EMBASE, CINAHL, Web of Science, Cochrane Database of Systematic Reviews, Cochrane Controlled Trials Register, Database of Reviews of Effectiveness, ACP Journal Club, and citation lists (1966 to January 2005).
Cohort studies published in English, French, Spanish, or Italian that compared clinical assessment with a reference standard.
The authors extracted standardized data, including setting, exclusions, population characteristics, reference standard, and results, and assessed quality against validated criteria.
The authors combined data by using random-effects meta-analysis and, if appropriate, used meta-regression to identify covariates that predicted diagnostic accuracy. Only malignancy (likelihood ratio [LR], 2.71), previous DVT (LR, 2.25), recent immobilization (LR, 1.98), difference in calf diameter (LR, 1.80), and recent surgery (LR, 1.76) were useful for ruling in DVT, while only absence of calf swelling (LR, 0.67) or difference in calf diameter (LR, 0.57) was useful for ruling out DVT. The Wells clinical score was more valuable than the individual characteristics; it stratified patients into groups with high (LR, 5.2), intermediate, and low (LR, 0.25) probability of DVT. The Wells score seemed able to stratify patients by risk only for proximal DVT, and it performed better in cohorts that were younger or excluded patients with previous thromboembolism.
Pooled estimates were subject to substantial heterogeneity. This may limit extrapolation between observers and settings. Only published studies were included, so findings may be subject to publication bias.
Individual clinical features are of limited value in diagnosing DVT. Overall assessment of clinical probability by using the Wells score is more useful.
*κ = 0.85. †κ = 0.86.
Appendix Table 1.
Two results are plotted from each study of the Wells score on the receiver-operating characteristic plane. Circles represent use of a high versus intermediate and low decision threshold (that is, only persons categorized as at high risk receive a diagnosis of deep venous thrombosis). Triangles represent a high and intermediate versus low decision threshold (that is, persons categorized as at high or intermediate risk receive a diagnosis of deep venous thrombosis). The point estimates and 95% CIs for pooled sensitivity and specificity for the 2 thresholds are also plotted as boxes.
Appendix Table 2.
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