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目的威尔斯规则等诊断预测模式可以安全排除疑似肺栓塞。然而,医生的自主可能性评估(格式塔理论)的利用也很常见。评估这两种方法在初级医疗中的诊断表现。方法家庭医生以0~100%的格式塔理论评分对肺栓塞的可能性进行评估,并计算转诊至二级医疗机构进行确诊的疑似肺栓塞患者598例的威尔斯评分。对比两种方法的识别能力(c统计量值)。之后,根据肺栓塞风险类别,将患者分层。对于格式塔理论,低于20%和D-二聚体试验阴性被视为低风险;对于威尔斯规则,4分及以下和D-二聚体试验阴性被视为低风险。对比灵敏度、特异度、有效率(在整个群组中的低风险患者比例)和失败率(被列入低风险的肺栓塞患者)。结果在随访3个月内,73例(12%)患者被确诊为静脉血栓栓塞(基线肺栓塞替代)。格式塔理论与威尔斯规则的c统计量值分别为0.77〔95%CI(0.70,0.83)〕和0.80〔95%CI(0.75,0.86)〕。通过格式塔理论识别的152例低风险患者中,有2例患者被遗漏,失败率为1.3%〔95%CI(0.2%,4.7%)〕,有效率为25%〔95%CI(22%,29%)〕;通过威尔斯规则识别的272例低风险患者中,有4例患者被遗漏,失败率为1.5%〔95%CI(0.4%,3.7%)〕,有效率为45%〔95%CI(41%,50%)〕。结论在初级医疗中,结合D-二聚体试验,格式塔理论分数低于20%和威尔斯规则分数为4分及以下的患者可排除肺栓塞的可能。且威尔斯规则更加有效,可以排除更大比例的疑似患者。
Objective Wells rules and other diagnostic prediction models can safely exclude suspected pulmonary embolism. However, the use of physician’s assessment of autonomy possibilities (Gestalt theory) is also common. Assess the diagnostic performance of these two methods in primary care. METHODS: Family physicians evaluated the odds of pulmonary embolism using a format tower theoretical score of 0-100% and calculated the Wells score of 598 suspected pulmonary embolism patients who were referred to a secondary care facility for diagnosis. Compare the recognition ability of both methods (c statistic). Later, the patients were stratified according to the risk category of pulmonary embolism. For formatting tower theory, sub-20% and D-dimer test negatives are considered as low risk; for the Wells rule, a score of 4 and below and a negative D-dimer test is considered as low risk. The sensitivity, specificity, efficiency (proportion of low-risk patients in the entire cohort) and failure rate (included in low-risk pulmonary embolism) were compared. Results Within 3 months of follow-up, 73 patients (12%) were diagnosed with venous thromboembolism (baseline pulmonary embolism replacement). The c statistic values of the formatter and Wells rules are 0.77 [95% CI (0.70,0.83)] and 0.80 [95% CI (0.75,0.86)], respectively. Two of the 152 low-risk patients identified by Gestalt theory were omitted, with a failure rate of 1.3% (95% CI, 0.2%, 4.7%) and an effective rate of 25% (95% CI, 22% , 29%)]; 4 of 272 low-risk patients identified by the Wells’ rule were omitted with a failure rate of 1.5% (95% CI 0.4%, 3.7%) and an effective rate of 45% [95% CI (41%, 50%)]. Conclusions In primary care, pulmonary embolism may be ruled out in combination with D-dimer testing in patients with a formatted tower theoretical score of less than 20% and a Wells rule score of 4 and below. And the Wells rules are more effective and can rule out a larger percentage of suspected patients.