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Semin Thromb Hemost 2012; 38(07): 691-701
DOI: 10.1055/s-0032-1327770
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

The Diagnosis of Venous Thromboembolism

Kerstin Hogg
1   Division of Hematology, Department of Medicine, University of Ottawa and the Ottawa Health Research Institute, Ottawa, Parkdale Clinic, Ottawa, Ontario, Canada
,
Philip S. Wells
2   Department of Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada
,
Esteban Gandara
1   Division of Hematology, Department of Medicine, University of Ottawa and the Ottawa Health Research Institute, Ottawa, Parkdale Clinic, Ottawa, Ontario, Canada
› Author Affiliations
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Publication History

Publication Date:
03 October 2012 (online)

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Abstract

Venous thromboembolism (VTE) is a serious and potentially fatal medical condition. Correct diagnosis and early treatment of VTE with anticoagulant drugs are critical steps in preventing further complications and recurrence. Evidence suggests that patients with suspected deep vein thrombosis (DVT) or pulmonary embolism (PE) should be managed with a diagnostic strategy that includes clinical pretest probability assessment, D-dimer test, and imaging. Clinical probability scoring, complemented by selective D-dimer testing, has become the recommended strategy for diagnosis. The reason is that overwhelming evidence suggests that patients with suspected VTE are better managed with a diagnostic strategy. If diagnostic algorithms are followed correctly, the chances of adverse events are extremely low (< 1%) in patients in whom VTE has been ruled out, whereas incomplete strategies leads to an increased risk of recurrent VTE or death. This review focuses on the application of diagnostic strategies with suspected DVT or PE into daily clinical practice while discussing the benefits and disadvantages of different approaches.

Keywords

pulmonary embolism - deep vein thrombosis - clinical prediction rules - D-dimer
 

  • References

  • 1 Spencer FA, Emery C, Lessard D , et al. The Worcester Venous Thromboembolism study: a population-based study of the clinical epidemiology of venous thromboembolism. J Gen Intern Med 2006; 21 (7) 722-727
    CrossrefPubMedGoogle Scholar
  • 2 Heit JA, Cohen AT. Anderson FA on behalf of the VTE Impact Assessment Group. Estimated Annual Number of Incident and Recurrent, Non-Fatal and Fatal Venous Thromboembolism (VTE) Events in the US. Paper presented at: American Society of Hematology meeting, December 10, 2005, Atlanta, Georgia
    PubMedGoogle Scholar
  • 3 Guyatt GH, Akl EA, Crowther M, Gutterman DD, Schuunemann HJ. American College of Chest Physicians Antithrombotic Therapy and Prevention of Thrombosis Panel. Executive summary: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141: 7S-47S
    CrossrefPubMedGoogle Scholar
  • 4 Wiener RS, Schwartz LM, Woloshin S. Time trends in pulmonary embolism in the United States: evidence of overdiagnosis. Arch Intern Med 2011; 171 (9) 831-837
    CrossrefPubMedGoogle Scholar
  • 5 Galanaud JP, Quenet S, Rivron-Guillot K , et al; RIETE INVESTIGATORS. Comparison of the clinical history of symptomatic isolated distal deep-vein thrombosis vs. proximal deep vein thrombosis in 11 086 patients. J Thromb Haemost 2009; 7 (12) 2028-2034
    CrossrefPubMedGoogle Scholar
  • 6 Ageno W, Agnelli G, Imberti D , et al; MASTER Investigators. Factors associated with the timing of diagnosis of venous thromboembolism: results from the MASTER registry. Thromb Res 2008; 121 (6) 751-756
    CrossrefPubMedGoogle Scholar
  • 7 Laporte S, Mismetti P, Décousus H , et al; RIETE Investigators. Clinical predictors for fatal pulmonary embolism in 15,520 patients with venous thromboembolism: findings from the Registro Informatizado de la Enfermedad TromboEmbolica venosa (RIETE) Registry. Circulation 2008; 117 (13) 1711-1716
    CrossrefPubMedGoogle Scholar
  • 8 Tapson VF. Acute pulmonary embolism. N Engl J Med 2008; 358 (10) 1037-1052
    CrossrefPubMedGoogle Scholar
  • 9 Tapson VF. Acute pulmonary embolism: comment on “time trends in pulmonary embolism in the United States”. Arch Intern Med 2011; 171 (9) 837-839
    CrossrefPubMedGoogle Scholar
  • 10 Stein PD, Fowler SE, Goodman LR , et al; PIOPED II Investigators. Multidetector computed tomography for acute pulmonary embolism. N Engl J Med 2006; 354 (22) 2317-2327
    CrossrefPubMedGoogle Scholar
  • 11 Courtney DM, Kline JA, Kabrhel C , et al. Clinical features from the history and physical examination that predict the presence or absence of pulmonary embolism in symptomatic emergency department patients: results of a prospective, multicenter study. Ann Emerg Med 2010; 55 (4) 307-315 , e1
    CrossrefPubMedGoogle Scholar
  • 12 Stein PD, Terrin ML, Hales CA , et al. Clinical, laboratory, roentgenographic, and electrocardiographic findings in patients with acute pulmonary embolism and no pre-existing cardiac or pulmonary disease. Chest 1991; 100 (3) 598-603
    CrossrefPubMedGoogle Scholar
  • 13 Rodger M, Makropoulos D, Turek M , et al. Diagnostic value of the electrocardiogram in suspected pulmonary embolism. Am J Cardiol 2000; 86 (7) 807-809 , A10
    CrossrefPubMedGoogle Scholar
  • 14 Gandara E, Wells PS. Diagnosis: use of clinical probability algorithms. Clin Chest Med 2010; 31 (4) 629-639
    CrossrefPubMedGoogle Scholar
  • 15 Wells PS, Anderson DR, Bormanis J , et al. Value of assessment of pretest probability of deep-vein thrombosis in clinical management. Lancet 1997; 350 (9094) 1795-1798
    Google Scholar
  • 16 Wells PS, Hirsh J, Anderson DR , et al. Accuracy of clinical assessment of deep-vein thrombosis. Lancet 1995; 345 (8961) 1326-1330
    CrossrefPubMedGoogle Scholar
  • 17 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 (2) 129-139
    CrossrefPubMedGoogle Scholar
  • 18 Cornuz J, Ghali WA, Hayoz D, Stoianov R, Depairon M, Yersin B. Clinical prediction of deep venous thrombosis using two risk assessment methods in combination with rapid quantitative D-dimer testing. Am J Med 2002; 112 (3) 198-203
    CrossrefPubMedGoogle Scholar
  • 19 Wells PS, Anderson DR, Rodger M , et al. Evaluation of D-dimer in the diagnosis of suspected deep-vein thrombosis. N Engl J Med 2003; 349 (13) 1227-1235
    Google Scholar
  • 20 Engelberger RP, Aujesky D, Calanca L, Staeger P, Hugli O, Mazzolai L. Comparison of the diagnostic performance of the original and modified Wells score in inpatients and outpatients with suspected deep vein thrombosis. Thromb Res 2011; 127 (6) 535-539
    CrossrefPubMedGoogle Scholar
  • 21 Ambid-Lacombe C, Cambou JP, Bataille V , et al. [Excellent performances of Wells' score and of the modified Wells' score for the diagnosis of proximal or distal deep venous thrombosis in outpatients or inpatients at Toulouse University Hospital: TVP-PREDICT study]. J Mal Vasc 2009; 34 (3) 211-217
    CrossrefPubMedGoogle Scholar
  • 22 Oudega R, Hoes AW, Moons KGM. The Wells rule does not adequately rule out deep venous thrombosis in primary care patients. Ann Intern Med 2005; 143 (2) 100-107
    CrossrefPubMedGoogle Scholar
  • 23 Oudega R, Moons KG, Hoes AW. Ruling out deep venous thrombosis in primary care. A simple diagnostic algorithm including D-dimer testing. Thromb Haemost 2005; 94 (1) 200-205
    PubMedGoogle Scholar
  • 24 Toll DB, Oudega R, Bulten RJ, Hoes AW, Moons KGM. Excluding deep vein thrombosis safely in primary care. J Fam Pract 2006; 55 (7) 613-618
    PubMedGoogle Scholar
  • 25 Büller HR, Ten Cate-Hoek AJ, Hoes AW , et al; AMUSE (Amsterdam Maastricht Utrecht Study on thromboEmbolism) Investigators. Safely ruling out deep venous thrombosis in primary care. Ann Intern Med 2009; 150 (4) 229-235
    CrossrefPubMedGoogle Scholar
  • 26 Toll DB, Oudega R, Vergouwe Y, Moons KG, Hoes AW. A new diagnostic rule for deep vein thrombosis: safety and efficiency in clinically relevant subgroups. Fam Pract 2008; 25 (1) 3-8
    PubMedGoogle Scholar
  • 27 Hogg K, Dawson D, Mackway-Jones K. Outpatient diagnosis of pulmonary embolism: the MIOPED (Manchester Investigation Of Pulmonary Embolism Diagnosis) study. Emerg Med J 2006; 23 (2) 123-127
    CrossrefPubMedGoogle Scholar
  • 28 Wicki J, Perneger TV, Junod AF, Bounameaux H, Perrier A. Assessing clinical probability of pulmonary embolism in the emergency ward: a simple score. Arch Intern Med 2001; 161 (1) 92-97
    CrossrefPubMedGoogle Scholar
  • 29 Perrier A, Roy PM, Aujesky D , et al. Diagnosing pulmonary embolism in outpatients with clinical assessment, D-dimer measurement, venous ultrasound, and helical computed tomography: a multicenter management study. Am J Med 2004; 116 (5) 291-299
    Google Scholar
  • 30 Perrier A, Roy PM, Sanchez O , et al. Multidetector-row computed tomography in suspected pulmonary embolism. N Engl J Med 2005; 352 (17) 1760-1768
    CrossrefPubMedGoogle Scholar
  • 31 Le Gal G, Righini M, Roy PM , et al. Prediction of pulmonary embolism in the emergency department: the revised Geneva score. Ann Intern Med 2006; 144 (3) 165-171
    CrossrefPubMedGoogle Scholar
  • 32 Righini M, Le Gal G, Aujesky D , et al. Diagnosis of pulmonary embolism by multidetector CT alone or combined with venous ultrasonography of the leg: a randomised non-inferiority trial. Lancet 2008; 371 (9621) 1343-1352
    CrossrefPubMedGoogle Scholar
  • 33 Lucassen W, Geersing GJ, Erkens PM , et al. Clinical decision rules for excluding pulmonary embolism: a meta-analysis. Ann Intern Med 2011; 155 (7) 448-460
    CrossrefPubMedGoogle Scholar
  • 34 Kline JA, Mitchell AM, Kabrhel C, Richman PB, Courtney DM. Clinical criteria to prevent unnecessary diagnostic testing in emergency department patients with suspected pulmonary embolism. J Thromb Haemost 2004; 2 (8) 1247-1255
    CrossrefPubMedGoogle Scholar
  • 35 Kline JA, Courtney DM, Kabrhel C , et al. Prospective multicenter evaluation of the pulmonary embolism rule-out criteria. J Thromb Haemost 2008; 6 (5) 772-780
    CrossrefPubMedGoogle Scholar
  • 36 Hugli O, Righini M, Le Gal G , et al. The pulmonary embolism rule-out criteria (PERC) rule does not safely exclude pulmonary embolism. J Thromb Haemost 2011; 9 (2) 300-304
    CrossrefPubMedGoogle Scholar
  • 37 Wells PS, Anderson DR, Rodger M , et al. Derivation of a simple clinical model to categorize patients probability of pulmonary embolism: increasing the models utility with the SimpliRED D-dimer. Thromb Haemost 2000; 83 (3) 416-420
    Article in Thieme ConnectPubMedGoogle Scholar
  • 38 Douma RA, le Gal G, Söhne M , et al. Potential of an age adjusted D-dimer cut-off value to improve the exclusion of pulmonary embolism in older patients: a retrospective analysis of three large cohorts. BMJ 2010; 340: c1475
    CrossrefPubMedGoogle Scholar
  • 39 Anderson DR, Kahn SR, Rodger MA , et al. Computed tomographic pulmonary angiography vs ventilation-perfusion lung scanning in patients with suspected pulmonary embolism: a randomized controlled trial. JAMA 2007; 298 (23) 2743-2753
    CrossrefPubMedGoogle Scholar
  • 40 Goekoop RJ, Steeghs N, Niessen RW , et al. Simple and safe exclusion of pulmonary embolism in outpatients using quantitative D-dimer and Wells' simplified decision rule. Thromb Haemost 2007; 97 (1) 146-150
    PubMedGoogle Scholar
  • 41 van Belle A, Büller HR, Huisman MV , et al; Christopher Study Investigators. Effectiveness of managing suspected pulmonary embolism using an algorithm combining clinical probability, D-dimer testing, and computed tomography. JAMA 2006; 295 (2) 172-179
    CrossrefPubMedGoogle Scholar
  • 42 Rodger MA, Maser E, Stiell I, Howley HE, Wells PS. The interobserver reliability of pretest probability assessment in patients with suspected pulmonary embolism. Thromb Res 2005; 116 (2) 101-107
    CrossrefPubMedGoogle Scholar
  • 43 Gandara E, Wells PS. Diagnosis: use of clinical probability algorithms. Clin Chest Med 2010; 31 (4) 629-639
    CrossrefPubMedGoogle Scholar
  • 44 Gibson NS, Sohne M, Kruip MJ , et al; Christopher study investigators. Further validation and simplification of the Wells clinical decision rule in pulmonary embolism. Thromb Haemost 2008; 99 (1) 229-234
    Article in Thieme ConnectPubMedGoogle Scholar
  • 45 Douma RA, Gibson NS, Gerdes VE , et al. Validity and clinical utility of the simplified Wells rule for assessing clinical probability for the exclusion of pulmonary embolism. Thromb Haemost 2009; 101 (1) 197-200
    PubMedGoogle Scholar
  • 46 Kabrhel C, Camargo Jr CA, Goldhaber SZ. Clinical gestalt and the diagnosis of pulmonary embolism: does experience matter?. Chest 2005; 127 (5) 1627-1630
    CrossrefPubMedGoogle Scholar
  • 47 Douma RA, Mos IC, Erkens PM , et al; Prometheus Study Group. Performance of 4 clinical decision rules in the diagnostic management of acute pulmonary embolism: a prospective cohort study. Ann Intern Med 2011; 154 (11) 709-718
    CrossrefPubMedGoogle Scholar
  • 48 Douma RA, Kessels JB, Buller HR, Gerdes VE. Knowledge of the D-dimer test result influences clinical probability assessment of pulmonary embolism. Thromb Res 2010; 126 (4) e271-e275
    CrossrefPubMedGoogle Scholar
  • 49 Goodacre S, Sampson FC, Sutton AJ, Mason S, Morris F. Variation in the diagnostic performance of D-dimer for suspected deep vein thrombosis. QJM 2005; 98 (7) 513-527
    CrossrefPubMedGoogle Scholar
  • 50 Luxembourg B, Schwonberg J, Hecking C , et al. Performance of five D-dimer assays for the exclusion of symptomatic distal leg vein thrombosis. Thromb Haemost 2012; 107 (2) 369-378
    Article in Thieme ConnectPubMedGoogle Scholar
  • 51 Fancher TL, White RH, Kravitz RL. Combined use of rapid D-dimer testing and estimation of clinical probability in the diagnosis of deep vein thrombosis: systematic review. BMJ 2004; 329 (7470) 821
    CrossrefPubMedGoogle Scholar
  • 52 Cogo A, Lensing AW, Koopman MM , et al. Compression ultrasonography for diagnostic management of patients with clinically suspected deep vein thrombosis: prospective cohort study. BMJ 1998; 316 (7124) 17-20
    Google Scholar
  • 53 Bernardi E, Prandoni P, Lensing AW , et al; The Multicentre Italian D-dimer Ultrasound Study Investigators Group. D-dimer testing as an adjunct to ultrasonography in patients with clinically suspected deep vein thrombosis: prospective cohort study. BMJ 1998; 317 (7165) 1037-1040
    CrossrefPubMedGoogle Scholar
  • 54 Kraaijenhagen RA, Piovella F, Bernardi E , et al. Simplification of the diagnostic management of suspected deep vein thrombosis. Arch Intern Med 2002; 162 (8) 907-911
    CrossrefPubMedGoogle Scholar
  • 55 Johnson SA, Stevens SM, Woller SC , et al. Risk of deep vein thrombosis following a single negative whole-leg compression ultrasound: a systematic review and meta-analysis. JAMA 2010; 303 (5) 438-445
    CrossrefPubMedGoogle Scholar
  • 56 Bernardi E, Camporese G, Büller HR , et al; Erasmus Study Group. Serial 2-point ultrasonography plus D-dimer vs whole-leg color-coded Doppler ultrasonography for diagnosing suspected symptomatic deep vein thrombosis: a randomized controlled trial. JAMA 2008; 300 (14) 1653-1659
    CrossrefPubMedGoogle Scholar
  • 57 McIlrath ST, Blaivas M, Lyon M. Patient follow-up after negative lower extremity bedside ultrasound for deep venous thrombosis in the ED. Am J Emerg Med 2006; 24 (3) 325-328
    CrossrefPubMedGoogle Scholar
  • 58 Hamadah A, Alwasaidi T, LE Gal G , et al. Baseline imaging after therapy for unprovoked venous thromboembolism: a randomized controlled comparison of baseline imaging for diagnosis of suspected recurrence. J Thromb Haemost 2011; 9 (12) 2406-2410
    CrossrefPubMedGoogle Scholar
  • 59 Burnside PR, Brown MD, Kline JA. Systematic review of emergency physician-performed ultrasonography for lower-extremity deep vein thrombosis. Acad Emerg Med 2008; 15 (6) 493-498
    CrossrefPubMedGoogle Scholar
  • 60 Blaivas M, Lambert MJ, Harwood RA, Wood JP, Konicki J. Lower-extremity Doppler for deep venous thrombosis—can emergency physicians be accurate and fast?. Acad Emerg Med 2000; 7 (2) 120-126
    CrossrefPubMedGoogle Scholar
  • 61 Sampson FC, Goodacre SW, Thomas SM, van Beek EJ. The accuracy of MRI in diagnosis of suspected deep vein thrombosis: systematic review and meta-analysis. Eur Radiol 2007; 17 (1) 175-181
    CrossrefPubMedGoogle Scholar
  • 62 Stein PD, Beemath A, Goodman LR , et al. Outcome studies of pulmonary embolism versus accuracy: they do not equate. Thromb Haemost 2006; 96 (2) 107-108
    PubMedGoogle Scholar
  • 63 Mathis G, Blank W, Reissig A , et al. Thoracic ultrasound for diagnosing pulmonary embolism: a prospective multicenter study of 352 patients. Chest 2005; 128 (3) 1531-1538
    CrossrefPubMedGoogle Scholar
  • 64 Stein PD, Chenevert TL, Fowler SE , et al; PIOPED III (Prospective Investigation of Pulmonary Embolism Diagnosis III) Investigators. Gadolinium-enhanced magnetic resonance angiography for pulmonary embolism: a multicenter prospective study (PIOPED III). Ann Intern Med 2010; 152 (7) 434-443 , W142-3
    CrossrefPubMedGoogle Scholar
  • 65 Stein PD, Woodard PK, Weg JG , et al; PIOPED II Investigators. Diagnostic pathways in acute pulmonary embolism: recommendations of the PIOPED II Investigators. Radiology 2007; 242 (1) 15-21
    CrossrefPubMedGoogle Scholar
  • 66 Ghanima W, Almaas V, Aballi S , et al. Management of suspected pulmonary embolism (PE) by D-dimer and multi-slice computed tomography in outpatients: an outcome study. J Thromb Haemost 2005; 3 (9) 1926-1932
    CrossrefPubMedGoogle Scholar
  • 67 Stein PD, Sostman HD, Bounameaux H , et al. Challenges in the diagnosis of acute pulmonary embolism. Am J Med 2008; 121 (7) 565-571
    CrossrefPubMedGoogle Scholar
  • 68 Ranji SR, Shojania KG, Trowbridge RL, Auerbach AD. Impact of reliance on CT pulmonary angiography on diagnosis of pulmonary embolism: a Bayesian analysis. J Hosp Med 2006; 1 (2) 81-87
    CrossrefPubMedGoogle Scholar
  • 69 Carrier M, Righini M, Wells PS , et al. Subsegmental pulmonary embolism diagnosed by computed tomography: incidence and clinical implications. A systematic review and meta-analysis of the management outcome studies. J Thromb Haemost 2010; 8 (8) 1716-1722
    CrossrefPubMedGoogle Scholar
  • 70 Pena E, Kimpton M, Dennie C, Peterson R, LE Gal G, Carrier M. Difference in interpretation of computed tomography pulmonary angiography diagnosis of subsegmental thrombosis in patients with suspected pulmonary embolism. J Thromb Haemost 2012; 10 (3) 496-498
    CrossrefPubMedGoogle Scholar
  • 71 Donato AA, Khoche S, Santora J, Wagner B. Clinical outcomes in patients with isolated subsegmental pulmonary emboli diagnosed by multidetector CT pulmonary angiography. Thromb Res 2010; 126 (4) e266-e270
    CrossrefPubMedGoogle Scholar
  • 72 Wells PS. Pulmonary embolism: a clinician's perspective. Semin Nucl Med 2008; 38 (6) 404-411
    CrossrefPubMedGoogle Scholar
  • 73 Gottschalk A, Stein PD, Sostman HD, Matta F, Beemath A. Very low probability interpretation of V/Q lung scans in combination with low probability objective clinical assessment reliably excludes pulmonary embolism: data from PIOPED II. J Nucl Med 2007; 48 (9) 1411-1415
    CrossrefPubMedGoogle Scholar
  • 74 Sostman HD, Miniati M, Gottschalk A, Matta F, Stein PD, Pistolesi M. Sensitivity and specificity of perfusion scintigraphy combined with chest radiography for acute pulmonary embolism in PIOPED II. J Nucl Med 2008; 49 (11) 1741-1748
    CrossrefPubMedGoogle Scholar
  • 75 Anderson DR, Kahn SR, Rodger MA , et al. Computed tomographic pulmonary angiography vs ventilation-perfusion lung scanning in patients with suspected pulmonary embolism: a randomized controlled trial. JAMA 2007; 298 (23) 2743-2753
    CrossrefPubMedGoogle Scholar
  • 76 Miniati M, Monti S, Bauleo C , et al. A diagnostic strategy for pulmonary embolism based on standardised pretest probability and perfusion lung scanning: a management study. Eur J Nucl Med Mol Imaging 2003; 30 (11) 1450-1456
    CrossrefPubMedGoogle Scholar
  • 77 Carrier M, Kimpton M, LE Gal G , et al. The management of a sub-segmental pulmonary embolism: a cross-sectional survey of Canadian thrombosis physicians. J Thromb Haemost 2011; 9 (7) 1412-1415
    CrossrefPubMedGoogle Scholar
  • 78 Salaun PY, Couturaud F, Le Duc-Pennec A , et al. Noninvasive diagnosis of pulmonary embolism. Chest 2011; 139 (6) 1294-1298
    CrossrefPubMedGoogle Scholar
  • 79 Miles S, Rogers KM, Thomas P , et al. A comparison of single-photon emission CT lung scintigraphy and CT pulmonary angiography for the diagnosis of pulmonary embolism. Chest 2009; 136 (6) 1546-1553
    CrossrefPubMedGoogle Scholar
  • 80 Le Gal G, Righini M, Sanchez O , et al. A positive compression ultrasonography of the lower limb veins is highly predictive of pulmonary embolism on computed tomography in suspected patients. Thromb Haemost 2006; 95 (6) 963-966
    PubMedGoogle Scholar
  • 81 Righini M, Le Gal G, Aujesky D , et al. Complete venous ultrasound in outpatients with suspected pulmonary embolism. J Thromb Haemost 2009; 7 (3) 406-412
    CrossrefPubMedGoogle Scholar
  • 82 Runyon MS, Richman PB, Kline JA ; Pulmonary Embolism Research Consortium Study Group. Emergency medicine practitioner knowledge and use of decision rules for the evaluation of patients with suspected pulmonary embolism: variations by practice setting and training level. Acad Emerg Med 2007; 14 (1) 53-57
    CrossrefPubMedGoogle Scholar
  • 83 Sampson FC, Goodacre S, Kelly AM, Kerr D. How is deep vein thrombosis diagnosed and managed in UK and Australian emergency departments?. Emerg Med J 2005; 22 (11) 780-782
    CrossrefPubMedGoogle Scholar
  • 84 Campbell S, MacDonald M, Carr B, Anderson D, MacKinley R, Cairns S. Bridging the gap between primary and secondary care: use of a clinical pathway for the investigation and management of deep vein thrombosis. J Health Serv Res Policy 2008; 13 (Suppl 1) 15-19
    CrossrefPubMedGoogle Scholar
  • 85 Vinson DR, Berman DR, Patel PB, Hickey DO. Outpatient management of deep venous thrombosis: 2 models of integrated care. Am J Manag Care 2006; 12 (7) 405-410
    PubMedGoogle Scholar