Assignment Paper

Implementing NICE guidelines and Trust guidelines for the Diagnostic investigations for DVT

Course: Delivering quality improvement in practice.
 
Implementing NICE guidelines and Trust guidelines for the Diagnostic investigations for DVT
Introduction
The sum of blood that solidifies in the body is referred to as a blood clot (Heit, Spencer, and White, 2016). Blood clots prevent the usual flow of the blood. On the other hand, venous thromboembolism occurs deep in the veins of the body, usually in the lower limbs. Heit (2015) notes that one to two people out of every 1000 suffer from deep vein thrombosis. The findings of the Centre for Disease Control and Prevention note that various symptoms of DVT affect nearly half of the total population. The massive pain within the body is a common symptom of DVT. Other notable symptoms include pain in the affected body parts, swelling of the legs or ankles, and reddish or pale skin in severe incidences.
The majority of people who are affected by DVT do not realize that they are suffering from this condition until a medical professional offers diagnosis (Raskob et al., 2017). In severe cases, patients suffering from VTE experience blood clots in the lungs and have difficulty in breathing. Since arteries are involved in the breathing system, blood clots in this region can also cause life-threatening complications and the desire to seek emergency help. The major causes of venous thromboembolism in the body include the blockage of deep veins as a result of blood clots. The damage of blood cells also causes blood clots. Weitz et al. (2017) point out that surgical procedures can be carried out incorrectly, thus damaging blood vessels and causing blood clots in the veins. Paul and Cifu (2019) opine that sitting for more extended periods, for instance, leads to the accumulation of blood in the legs, which can cause blood clots. There is a need, therefore, to be concerned about blood clots that contribute to VTE. Heit et al. (2016) also explain that a reduction in various body functions, the flow of blood movement is equally lowered and can lead to clotting of blood in the veins. The World Health Organization reports that in every twenty people, one of them will be affected by VTE during their lifetime. Carey (2017) also agrees with these recommendations noting that there is a need to explore various mechanisms of treating VTE and their benefits to patients.
Currently, Paul and Cifu (2019) believe that there is a need to improve the treatment and diagnosis of VTE and DVT. There is limited emphasis on the recommendations of the NICE Global guidelines, which can be used to determine various diagnostic tests. Further, the majority of patients are referred to undergo complicated and expensive scans without proper diagnosis. Raskob et al. (2018) also showed that the Wellscore diagnostic tool had not been utilised appropriately, and many patients undergo Doppler scans without intention. The reluctance to follow guideline requirements is impactful as patients may be forced to pay expensively for medical procedures, which are administered as stipulated (Heit, 2015). The purpose of this study is to investigate the methods of treating VTE and DVT, side effects, and their efficacy in improving the quality of life. The recommendations and conclusion of this study can form useful learning points for various medical practitioners in dealing with patients who suffer from VTE and DVT.
Aims of the Study
The main aim of this study is to explore the current diagnostic and treatment methods. Through an in-depth investigation, the study evaluates research gaps to improve current practice. The study also seeks to boost available knowledge to the staff at the ambulatory care, accident, and emergency units to avoid unnecessary admissions. The study also provides recommendations for proper measures of treating DVT patients hence improving the healthcare and service delivery to DVT patients.
Objectives of the Study
The objectives of this study include:
i. To evaluate the data to assess the referral procedure against the proper and relevant guidelines for DVT to obtain relevant data on patient pre-clinic/referral assessment.
ii. To perform the risk assessment of any new recommendations for the treatment of the DVT
iii. To evaluate the cost-effectiveness of the recommended treatment methods for DVT
iv. To recommend, lead, and implement change in delivering quality improvement in nursing practice.
Implementation Plan
Materials & Methods
Literature search was conducted to gather evidence of the review questions based on the NICE guidelines. Clinical and medical databases were identified for searching with the systematic selection of subheadings, medical text terms, and appropriate study filters. Databases like Embase, PubMed, MEDLINE, Cinahl, and Cochrane library were utilised in the search. Strategies for searching were adopted according to the aim of the study and the essential papers and articles related to the heading of the study. The searches and reports for guidelines were borrowed and hugely relied on the listed websites and organizations.
i. National Institute for Health and Clinical Excellence (NICE) (www.nice.org.uk)
ii. Guidelines International Network database (www.g-i-n.net)
iii. National Guideline Clearing House (www.guideline.gov/)
iv. National Institutes of Health Consensus Development Program (consensus.nih.gov)
v. National Library for Health (www.library.nhs.uk/)
 
The keywords and search terms used in the search engines of the databases include:
Database Medical Subject Heading (MeSH) Keywords/ Search Terms
MEDLINE Thesaurus MeSH Diagnosis of DVT, Diagnosis of VTE, Diagnosis of PE
PubMed Thesaurus MeSH Examination of Cancer, Diagnosis of Thrombophilia
Embase Thesaurus MeSH Diagnosis of PE
Cinahl Thesaurus MeSH Diagnosis of Thrombophilia
Cochrane Thesaurus MeSH Examination of Cancer
PICO Framework
The clinical literature was reviewed according to the PICO framework, including all the protocols, patients, interventions, comparison, and the outcome. The PICO framework was undertaken to guide the literature search in facilitating the appropriate recommendations for the implementation of NICE guidelines. NICE guideline manual has provided for the different clinical areas for the lookout in the diagnosis for DVT, and the study provided for review questions based on the guidelines.
 
Framework Item Answer
Patient/ Problem/ Population Deep Vein Thrombosis (DVT); Venous Thromboembolism (VTE); Blood clot in veins
Intervention D-dimer Test
Comparison/ Control Wells score Test, Ultrasound, CT Scan
Outcome Regular Blood Flow/No blood clots

Literature Search Strategy
In Deep Vein Thrombosis Does D-dimer test compared with the Wells Score Test improve/reduce Regular Blood flow
(P) Patient/Population/Problem (I) Intervention (C) Comparison (O) Outcome
P
I C O
Main term Deep Vein Thrombosis (DVT); D-dimer Test Wells score Test Regular blood flow
Alternative term/synonym
Venous Thromboembolism (VTE);

N/A

Ultrasound

No blood clots
Alternative term/synonym

A blood clot in veins

N/A

CT Scan

N/A

Inclusion and Exclusion Criteria
The research followed the next criteria. Abstracts and titles were identified for searching and reviewing as related to each question. Full articles were then obtained, reviewed, and the information arranged systematically. The outcomes and evidence were analysed, including randomised studies that involved recommendations of assessment of clinical studies, evaluation of the studies, and how they were developed. Observational studies were equally recorded and the data presented in the auditing report. The studies that involved the assessment of the NICE guidelines checklist for practical recommendations and the criteria advised for diagnosis. The necessary standard requirements were analysed and presented after the evaluation of quality value in practice.
Inclusion Criteria Exclusion Criteria
Health materials and other cohort studies Letters, people’s opinions, study reviews, abstracts, editorials, and unpublished research and studies
Studies involving assessment of the NICE guidelines checklist for practical recommendations and diagnosis Laboratory results and tests

 
PRISMA Flow Diagram

 
Literature Providing Data for Evidence for DVT and PE
Previous research has been dedicated to investigating the most comfortable way and medical approach to treating DVT (Cuker et al., 2019). The Centre for Disease Control and Prevention acknowledges that there is a need for improvements in the service delivery of DVT. The centre also recognises that there are conditions with the same symptoms as DVT. There is a need for an in-depth analysis of a situation before diagnosis. The findings further acknowledge that conditions like cellulitis, muscle injury, and inflammation of veins under the skin may exhibit similar symptoms as DVT. Heart attack and pneumonia may also have signs like those of VTE (Paul and Cifu, 2019). In this regard, individual tests are required to assess clots in vein surfaces and lungs. The Centre for Disease Control and Prevention has also introduced a diagnosis plan for DVT- the Duplex ultrasonography tool.
Duplex ultrasonography is a test that determines the flow of the blood in the veins. The imaging tool utilises sound waves technology to detect blockage and blood flow in the veins (National Institute for Health and Clinical Excellence, 2009). Through the use of sound, the device can detect blood blockage and any blood clots in the deep veins. The Centre for Diseases Control further recognises Duplex ultrasonography as the standard imaging tool for the diagnosis of DVT. Other notable tests for DVT include the D-dimer blood test. This test measures the substances that are released in the blood when a blood clot breaks. The presence of elements signifies blood clots, meaning that the patient is likely to suffer from DVT. A negative result means that the patient has no blood clots (NICE, 2012).
Notably, another diagnosis for DVT is the contrast venography that is an X-ray procedure in which contrast fluid-like dye is injected in a patient’s central veins in the leg or ankle. A nurse or medical practitioner can monitor the state of the veins and the movement of the blood (Greenall, 2017). The Centre for Disease Control recognises this tool as the most accurate for diagnosing blood clots in the veins. However, the test is considered risky, and it is only used in specific cases to reduce the implications it may cause.
The magnetic resonance imaging, which uses radio waves and magnetic field patterns to provide the images, can also be used to monitor a patient’s body. The test also incorporates computed tomography, a typical CT scan test used by medical practitioners to screen and scan body organs (Tritschler et al., 2018). In summary, these tests are used to provide images of veins helping doctors see the blood clots. The Centre for Disease Control argues that the above tests are efficient in diagnosing of deep vein thrombosis.
Diagnostics Investigation of DVT as per NICE Guidelines
When a patient appears before a practitioner with DVT symptoms, the practitioner is required to study the medical history of the person. A medical history will involve the patient informing the practitioner about symptoms and any other affiliated diseases (Niimi et al., 2010). A practitioner will carry out a physical examination to rule out other conditions exhibiting the same symptoms, such as cellulitis.
In the event of ruling out all other probable illnesses, practitioners are likely to suspect deep vein thrombosis. A DVT Wells score, a tool that is designed for clinical estimation of DVT can be deployed (Wells et al., 2006). In the Wells score, the doctor will assess the probability of active cancer, ongoing treatment, and a possible scenario within the last six months. The practitioner will also assess the possibility of paralysis or the possible recent plaster immobilisation in extreme cases like pulmonary embolism.
Further, a practitioner will also assess the possibility of localized tenderness enhancing distribution in the deep vein system. The practitioner will evaluate if there is calf swelling of more than 3cm asymptomatic part (Wells et al., 2006). The medical officer can examine if the leg is swelling or is already swollen. The practitioner will also have to look at previous records of DVT in the patient, if any, previous tests. When examining the above cases and scenarios, the practitioner has to award points per each finding according to the results of their findings. The points will help them in propagating the probability of DVT in a patient.
Two-Level DVT Wells score table
Clinical Test Points
Active cancer in the patient 1
possibility of the paralysis 1
Bedridden period 1
Possibility of localized tenderness 1
Calf swelling 1
Leg Swelling 1
Edema in the affected leg 1
Non-varicose veins 1
Previous DVT records 1
Alternative treatments -2
A simplified score for clinical probability of DVT
Possibility of DVT Above 2 points
The unlikely possibility of DVT Below 2 points
Source: Wells PS et al. (2003)
The scores, as outlined above, predict the situation of a patient. If the patient scores more than two points in all the tests, he is likely than not suffering from DVT (Hemingway, 2009). The practitioner undertakes the responsibility of carrying out a proximal leg vein ultrasound examination in a period of fewer than four hours after the Wells score tool analysis. In case the ultrasound gives a negative result, then the practitioner should go for a Dimer-tests. The test has to be carried out 24 hours after the ultrasound scan (Veiga et al., 2000). If the ultrasound was not carried out within the four hours, then their requirement of a Dimer-test and a temporary 24-hour dosage of parenteral anticoagulants before conducting a proximal leg vein ultrasound examination is carried out immediately after anticoagulant dose elapsing period (the 24 hours).
After six days, the practitioner is supposed to repeat the proximal leg vein ultrasound scanning for all the patients who tested positive in the dimer-test a negative in the first proximal leg vein ultrasound examination (Aguilar and del Villar, 2005). In the Wells score table, patients may have generated the unlikely possibility of the DVT, does not rule out the incidence of DVT (Wells et al., 2003). In this case, the practitioner should also conduct a Dimer-test, and if positive, then the practitioner may perform the following further investigations.
The first step is to perform a proximal leg vein ultrasound examination in four hours’ period after Dimer-test, or in case the ultrasound was not carried out within the four hours then there requires a Dimer-test and a temporary 24 hours’ dosage of parenteral anticoagulants then proximal leg vein ultrasound examination is carried out immediately after anticoagulant dose elapsing period which is 24 hours (Wells et al., 2003). The next step is diagnosing and treating the patients with DVT, that test positive in proximal leg vein ultrasound examination.
The alternatives diagnoses should be considered for a patient that exhibited unlikely possibility of DVT in the Two-level DVT Wells score but; Tested negative in the D-dimer test or Tested positive in D-dimer test but negative on the proximal leg vein ultrasound examination. A patient that exhibited the possibility of DVT in the Two-level DVT Wells score but; Tested negative on proximal leg vein ultrasound examination and positive on D-dimer test or Tested negative on proximal leg vein ultrasound after the D-dimer test. In the above two scenarios, the practitioner is supposed to advise the patients on their DVT status, and take them through the signs and symptoms of DVT while offering a way forward (Wells et al. 2003).
Investigation for Pulmonary Embolism
Practitioners should be accurate in the diagnosis process, making sure they diagnose the right condition. In this case, professionals must also consider testing the patient of pulmonary embolism. If a patient exhibits symptoms of PE, the process of investigation is just like that of DVT. However, their Wells score table is different from those of suspected DVT (Wells et al., 2000). In this case, the practitioner will test the following; any minimal clinical signs of DVT like swelling of legs and abnormal pain in the veins, previous records of DVT, Heartbeat rate in 100 beats, immobilisation for more than three days, or a surgery that has lasted less than four weeks (Alves, Batel-Marques, and Macedo, 2012). They will also test hemoptysis and malignancy along with finding alternatives for the treatment of the PE.
Two-Level PE Well Score
Source: Wells et al. (2000)
Patients suspected of PE after analyses of the signs and symptoms of their conditions but give likely scores in the table above are offered either computed tomography pulmonary angiogram (CTPA). Temporary parenteral anticoagulant therapy, then followed by computed tomography pulmonary angiogram (Wicki et al., 2001). In case the computed tomography pulmonary angiogram is negative, the practitioner should consider conducting an ultrasound scan on the patient. Patients who show signs suspected of PE but show unlikely results from the two-level PE Well score should be offered D-dimer test (Carrier, Wells, and Rodger, 2006). If the results are positive, then the patient should be provided with an immediate computed tomography pulmonary angiogram or temporary parenteral anticoagulant therapy, then followed by computed tomography pulmonary angiogram.
Diagnosis for Active Cancer
Patients with suspected symptoms of deep vein thrombosis and pulmonary embolism should be offered a test for cancer as the first procedure of the DVT diagnosis. The procedure has been outlined in the Two-level Wells score table. Guideline number 144 of the NICE requirements appeal to the practitioners to make cancer testing in the procedure of conducting any cause of VTE variables (Piccioli et al., 2004). Cancer and VTE have not been proven historically. However, the current clinical settings require investigation into all probable causes of VTE to identify any condition that may be affected by the patient.
Practitioners should ensure that the examination process of VTE is well-strategised to prevent cases of wrong diagnoses. Practitioners should ensure that patients with venous thrombosis symptoms receive recommendations for cancer investigation and other essential services that provide cancer investigation to the patients take place. However, cancer investigation to patients may incur additional costs. NICE guidelines anticipate that 20% of suspected VTE symptoms patients will require diagnosis that reveals unprovoked VTE in them (White, 2008), earning them a chance for cancer investigation.
Further, NICE guidelines have recommended the following requirements: physical testing, which includes blood tests, a blood test including blood counts in the body, serum calcium, and liver testing. The NICE guidelines also provide that advanced tests for pregnant women and all other patients aged above 40 years and above like abdominal CT scans and mammograms for cancer who have displayed unprovoked signs of DVT and PE (Righini et al. 2014). Moreover, those patients that initially shown no signs of cancer in the primary investigation are also required to go for this investigation. During these processes, additional costs may be incurred due to these additional procedures. If by chance, an individual is found with cancer in this stage while they also have DVT, individuals should be subjected to anticoagulant therapy.
The NICE guideline (144) indicates that patients with cancer and exhibits unprovoked symptoms of DVT and PE should LMWH for not less than six months rather than the average vitamin K offered to patients for three months (Gibson et al., 2008). This imposition is yet to be implemented in our health systems. Whereas there are relevant recommendations for the right procedures to be followed, they are yet to be initiated in our health care. Therefore, before the implementation of this guideline, practitioners are required to ensure that patients with active cancer specify in their local treatment and procedures to make sure that patients receive six months of anticoagulant therapy (Ansell, Mahaffey, and Garcia, 2020).
Investigation for Thrombophilia
The examination of thrombophilia among patients with VTE does not result in any meaningful benefit. The patient may also be subjected to psychological suffering that could result in stress and anxiety to them, affecting their treatment plan (Mahan et al., 2012). In this regard, patients should not be subjected to unnecessary thrombophilia testing (Pierre et al., 199, pp190-195). Practitioners should make sure that patients are not directed to thrombophilia testing, especially if they have unprovoked symptoms of VTE, as provided in guideline 144 of the NICE requirements (Nation and Chronic, 2010). The quality implementation of the right procedure is essential to enhance effectiveness in handling DVT.
Quality Assessment of Findings for Diagnosis
Outcome Studies reviewed Results in percentage Clinical Tests Quality
Sensitivity 26 High above 90 percent Well score Moderate
Specificity 20 High above 90 percent Well score Moderate
Sensitivity 8 75-100 % D-dimer Low
specificity 8 26-83% D-dimer low
Sensitivity 6 93-94 Ultrasound scans moderate
Specificity 6 71-100 Ultrasound scans Very low
The Enhancement of Safety and Quality Deliverance of Services
The current NICE guidelines need to be implemented in entirety to enhance effective services to the patients. The guidelines provide a clear overview of what is required of practitioners in their responsibilities to make sure that patients’ safety is prioritised while they are undergoing a diagnosis of DVT. In order to impose a different approach in implementing the guidelines, the study proposes the following solutions in delivering services. When a patient presents any signs of DVT, the practitioner should carry out the patient’s medical history and other physical tests to eliminate the probability of other conditions with the same symptoms.
The easiest way to generate the probable value of outcome causes is initiating an investigation that focuses on the alternative diagnosis of other probable cause that explains the symptoms. The process will provide the most straightforward way of determining the condition and enable the practitioner to identify the situation. Further, enquiring about the medical history and physical testing of the patient does not hold any possible risk or harm to the patient. It may lead the practitioner into other conditions or exclude signs of the suspected DVT condition. Finishing this diagnosis procedure is essential as it creates a real way for the probable cause of action to be taken for the patient’s condition.
The study weighs heavily on this practice as it figures out that the practice has a high effect on the probable outcome that is essential to the patient. Therefore, an implementation of this practice will mean good returns on reducing variations in practice. Thus, the outcomes will facilitate the proper usage of NHS resources in the motive of promoting equality in care. Sensitivity is the most underlying and reliable outcome in ruling out DVT in a patient. There are costs incurred in carrying out unnecessary tests and missed cases of DVT.
However, the recurring expenses in this test are lesser to the costs that would be incurred in missed cases. In this case, the three-level and the two-level Wells score testing for DVT are necessary. There is a possibility of scanning every single point in both tests. However, to improve service delivery, a two-level version is efficient and reliable, for it takes into account the patient’s previous records of DVT and then expands the probable to the post-surgery period that is considered to be risks, four to twelve weeks. Therefore, the two-level Wells score should be implemented for effective delivery of service.
In this study, the recommendation of a two-level score test was not based on cost but reliability purposes. However, the number of studies considered for this test exhibited a number of limitations on the sensitivity value in the evidence of practice. This is because they relied on the three-level score that is not appropriate and recommended model in this study. The effect was facilitated by the diversity witnessed in the study settings and populations. For ethical consideration purposes, this model will exhibit severe economic limitations. Wells score tests should be used alongside other tests. When the test is used with D-dimer test unlikely probability score is possible that putting a patient at a pre-probability ruling out DVT. To arrive at this decision, practical and professionalism was considered; the Wells score test model (original and the modified two-level model) were configured as the most considered scores in pre-probability tests and that are widely used. When a dichotomous system (likely and unlikely) is used in reporting scores, there are limited chances of confusion, and thus they are easier to implement. The purpose of training healthcare professionals is to identify patients with the DVT and initiate appropriate further methods and send those without DVT home without involving inappropriate methods that would incur unnecessary expenses.
The diagnosis and treatment of DVT are less risky and non-invasive. Specificity and sensitivity is a vital outcome here. In that regard, then the D-dimer test is the most effective in ruling out DVT. In case of sensitivity increases, then it means few patients with DVT are missed, and the proportion of the patients testing a false positive may increase. This can result in more patients sent for inappropriate further investigation and treatment, which drains patients’ and NHS resources. A D-dimer test is recommended for that purpose.
A D-dimer test has high sensitivity and low specificity. This means that false-positive results are always expected. Therefore, a D-dimer test to be considered for further investigation, then it should have a high sensitivity and high negative value. This way, only a few people with VTE will be missed. This means that a negative D-dimer test has a high determining value of DVT, while a positive D-dimer test has no value in the diagnosis of DVT. The negative d-dimer test is valuable in excluding the diagnosis DVT of a patient whose pre-probability test gave unlikely results, and it is not good enough in determining the diagnosis approach of patients whose pre-probability test gave likely results. The proximal leg vein ultrasound tests are used for confirmation purposes in these tests. In this examination, sensitivity and specificity are essential in ensuring all the DVTs are detected in the suspected patient and that no patient without DVT is given heparin.
Proposed Outcomes
The anticipated outcomes for this study include:
i. Improved patient experience and outcomes and the implementation of a more robust system based on NICE guidelines utilizing practical assessment tools for DVT, such as Wells score before investigations.
ii. A personal improvement of leadership and management skills in the profession through learning management of the systems for the diagnosis and treatment of DV.
Conclusion
The diagnosis of VTE should be considered as the most critical step in the process of treatment. The process should be carried out with the utmost care to ensure that only the rightful condition is recommended for further investigation. Following audit studies at the ambulatory care unit, there is a need for service improvement. A practitioner should carry out the diagnosis of DVT and VTE carefully to limit the chances of misdiagnosis. There is a need for practitioners to consider the medical history of a patient before initiating any diagnostic approach. The medical history will help the practitioner in ruling out other probable causes of diseases in a patient. Further, a physical examination is an essential process for any practitioner to initiate in a patient. An in-depth evaluation of a condition can help in ruling out the possibility of the DVT in a patient. In summary, the plan for service delivery in medical assessment and physical examination outlined in this paper should be considered as the key priority to implement.
A D-dimer test is necessary for ruling out DVT in a patient. However, the process of analysis is limited to its sensitivity. The higher sensitivity in the test means that portraying positive results in a patient even when the patient has no DVT. Therefore, the test requires an additional test, like ultrasound scanning, for confirmation. The proximal leg vein ultrasound scanning is an essential diagnostic tool in ruling out the occurrence of DVT in patients. The test is used for confirmation purposes in ensuring that no patient is wrongly prescribed. There is a need to note that heparin poses more significant side effects for the patients when wrongly administered, posing health problems to patients who initially had no issue. Therefore, ultrasound scanning should be systematically initiated on a patient to make sure that there are no unidentified blood clots in the veins.
Practitioners should diagnose and confirm cases of suspected DVT to initiate treatment plans as soon as possible, to avoid deteriorating states of the patient. Healthcare professionals should initiate an affordable diagnosis plan to patients and process the procedure as quickly as possible to relieve patients or to recommend further investigations for those found with DVT. A Well score probability test and D-dimer test are some of the safest tests to examine patients and impose the proper measures in the diagnosis of DVT. Delays in conducting ultrasounds to patients are a problem and hold the potential risk to the patients, and they should be avoided as much as possible. Anticoagulants should be administered within a 24-hour period, especially in situations where there is a need, including possible delays in conducting ultrasound. Patients suspected to have unproved signs of DVT should not be released for home-based care on the basis of their negative D-dimer tests. Ultrasounds should be conducted despite their underlying risks. Patients with likely scores in the Well score test and supported by a positive ultrasound scan results confirm that they have DVT, and recommendations for further investigations should be initiated immediately.

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Summary of Systematic Reviews/Literature
No. Articles Aim Data size Methodology Quality Appraisal/Limitations Main findings
1. Alves et al. (2012), United Kingdom To compare the therapeutic indications of apixaban, rivaroxaban, and Xa coagulation factor direct inhibitors through direct experimental safety 12
Secondary Quantitative
There were no significant differences between the studied drugs Apixaban has fewer chances of bleeding and thus has a lower risk of hemorrhage

2. Aguilar and Del Villar, 2005) the United States To evaluate a quantitative immunoturbidimetric assay for diagnosis of DVT 18
Quantitative
There were very few reports addressing the diagnostic outcome for patients with SVT D-dimer is a useful diagnostic approach for the exclusion of DVT
3. Carrier et al. (2017) the United States To compare the diagnostic test features of various approaches to assigning pre-test probability 535
Primary Quantitative
The Wells score with a cutoff of 2 was limiting, hence excluded some of the participants A semi-quantitative D-dimer has to be carefully combined with a safer clinical probability assessment to form the exclusion criteria of pulmonary embolism
4. Cuker et al. (2017), United States To evaluate the suitability of idarucizumab and andexanet alpha as direct oral anticoagulants. 2
Descriptive
There were very few suggestions for anticoagulants included in this research Non-specific prohemostatic agents including prothrombin concentrate can also be used as direct oral anticoagulants
5. Mahan et al. (2012) the United States To define the costs of PE and VTE annually for estimation of US healthcare costs 3 Secondary Qualitative
The results and recommendation for this study are limited to the United States only When effective VTE strategies are prioritised, the cost of healthcare, morbidity, and mortality will reduce significantly
6. Niimi et al. (2010), Japan To evaluate the importance of soluble fibrin and D-dimer assays for the diagnosis of postoperative DVT 207 Quantitative
This study suggests that soluble fibrin can also be used as an alternative to the D-dimer test in the diagnosis D-dimer tests and soluble fibrin gets cannot be used solely in as much as they are valuable screening tools.
7. Perrier et al. (1999), Switzerland To assess the non-invasive diagnosis of venous thromboembolism in outpatients 918 Quantitative
This study combines various approaches in diagnosis to determine a safe method A suitable diagnostic strategy is to combine clinical assessment, D-dimer, lung scans and ultrasonography to diagnose outpatients with VTE
8. Piccioli et al. (2004) Italy To evaluate the impact of extensive screening for occult malignant idiopathic VTE patients 201 Quantitative
Occult cancer diagnosis even at the onset does not necessarily translate to treatment In as much as detecting cancer much earlier improves treatment chances, there is no proof of an improvement in prognosis
9. Righini et al. (2014), the United States To validate if a D-dimer cut off with age adjustment in patients who are older than 50 years 3346 Quantitative
A clinical probability test coupled with a D-dimer test is a better approach to diagnosis The diagnostic strategy failed during the three-month trial period as patients were not treated with anticoagulants due to negative D-dimer age adjustments
10. Tritschler et al. (2018) Canada To evaluate the advanced in the treatment and diagnosis of VTE over the past 5 years 32 Secondary Qualitative
There have been several approaches to diagnosis tailored to individual preferences Anticoagulation is no longer indicate a low risk of recurrence for patients with isolated deep vein thromboembolism
11. Veiga et al. (2000) Spain To evaluate the safety and applicability of lower weight molecular heparin for older adults 100 Primary Quantitative
The results of this study are not conclusive due to a wide confidence interval A fixed-dose of enoxaparin is effective and safe in the treatment of DVT
12. Wells et al. (2003) Canada To evaluate the safety of various diagnostic approaches 530 Primary Quantitative
There is no need for ultrasound in cases of negative D-dimer test results DVT can be ruled out if a patient is judged clinically, especially if the D-dimer test is negative.
13. Wells et al. (2000) Canada To develop a significant scoring system, that can be integrated with D-dimer tests 40
Primary Quantitative
There is a need to carry out additional tests to determine the accuracy of D-dimer tests A negative D-dimer test result can safely exclude PE among patients who are suspected of the condition
14. Wells et al. (2006) Canada To review clinical trials which predict the prevalence of DVT with or without D-dimer tests 14 Secondary Qualitative
This study does not answer its research questions conclusively The accuracy of diagnosis improves if the clinical probability is estimated before diagnostic tests
15. Wicki et al. (2001), Switzerland To develop a simple clinical score for emergency patients suspected with pulmonary embolism 1090 Primary Quantitative
This study recommends that the use of the generated score can help diagnose in emergency situations A clinical score based on available parameters is a suitable clinical assessment tool for pulmonary embolism
16. Vongchaiudomchoke and Boonyasirinant (2016) Thailand
To evaluate the prevalence of positive CTA in recent clinical predictions 300 Primary Quantitative
This study emphasizes the importance of accuracy to limit patient’s care costs Positive pulmonary CTA is unlikely to occur in patients with positive D-dimer tests or does not have thromboembolic factors
17. Van Es et al. (2015) the Netherlands To evaluate the negative D-dimer diagnostic approach, and improve its efficiency 723
Primary Quantitative
The results of this study should be evaluated in detail before implementation When the items of a Wells score are combined with a D-dimer test, a simplified decision can be formulated
18. Aguilar and Del Villar (2005), United States To investigate the D-dimer assay in the diagnosis of venous thrombosis 20 Observational prospective study The articles did not contain a quantitative analysis of the D-dimer test D-dimer assays are not a preferred method for testing superficial venous thrombosis.
19. Anderson et al. (2003) the United States To assess the clinical probability of other diseases in patients suffering from deep vein thrombosis 98 Quantitative The recommendation of this study cannot be utilised in cases where there are many PE patients The use of ultrasound can be used to omit incorrect diagnosis
20. Owen et al. (2006), United States To assess the prevalence of DVT through clinical prediction rules 35 Quantitative Patients who have higher clinical judgments of DVT should be subjected to ultrasounds Patients who show negative for D-dimer tests should undergo further diagnosis with ultrasound
21 Raskob et al. (2018), United States To investigate the role of treatment with direct oral anticoagulants 1050
Primary Quantitative
The rate of recurrence was lower with a higher bleeding rate
Edoxaban can be used to treat VTE associated with cancer to replace low weight heparin

22 Weitz et al. (2017), United States To differentiate the efficacy of lower or full intensity anticoagulants 3396
Primary Quantitative
This study did not differentiate the significance of bleeding rates
Rivaroxaban has a lower incidence of VTE recurrence

23 Spyropoulos et al. (2018), United States To evaluate the role of extended thromboprophylaxis in treating controversial patients 12024
Primary Quantitative Rivaroxaban did not actually lower fatal VTE 45 days after discharge Rivaroxaban is active in 45 days after discharge and does not have any significant risk of death

24 Heit (2016), United States To determine the epidemiology of VTE
12
Qualitative
The possible recurrence of VTE is higher even after prophylaxis
Primary and secondary prophylaxis is an effective treatment method for recurring VTE
25 Gerhardt et al. (2016), Germany To investigate a suitable mechanism of treating acute VTE during pregnancy 3 Secondary Qualitative
There is a need to define the duration and intensity of anticoagulant treatment
Anticoagulants should be used within 6 weeks or not less than 3 months