Clinical Question: What is the best management strategy for patients with suspected deep venous thrombosis (DVT)?

Setting: Various (meta-analysis)

Study Design: Cost-effectiveness analysis

Synopsis: The authors systematically reviewed the literature and identified 18 different strategies for managing patients with suspected DVT. They evaluated a hypothetical group of 1,000 patients using each algorithm, applying reasonable estimates of test accuracy, treatment effectiveness, and the cost of testing and treatment. This included the cost of applying a clinical decision rule, such as the Wells rule. They estimated a mean survival of 11.6 quality-adjusted life years after diagnosis of DVT at age 60. The estimates were reasonable and most of the algorithms used some combination of the Wells rule, D-dimer, and venous ultrasonography.

The percentage of patients with proximal DVT who would be treated appropriately by the algorithms ranged from 90.1 to 99.5 percent, and the patients without DVT treated inappropriately ranged from 0.6 to 6.0 percent. The optimal algorithm used a latex D-dimer test as the initial screen. If patients were D-dimer negative and had a low or intermediate Wells score, DVT was considered ruled out. If they were D-dimer negative but at high risk based on the Wells score, an above-knee venous ultrasound examination was ordered. If the examination was positive, they were treated; if negative, a repeat examination was ordered. Patients who were D-dimer positive underwent ultrasound examination: if positive, they were treated; if negative, they had a repeat examination. Several other algorithms were similarly cost-effective.

Bottom Line: The most cost-effective algorithm for managing patients with suspected DVT was identified, although several are nearly as good. The main message is that the best approach to DVT uses the combination of a validated clinical decision rule, D-dimer test, and venous ultrasound examination. (Level of Evidence: 1b)