How should we diagnose suspected deep-vein thrombosis?
From the 1Medical Care Research Unit and 2Health Economics and Decision Science, University of Sheffield, Sheffield, 3Department of Health Sciences, University of Leicester, Leicester, and 4Sheffield Vascular Institute, Northern General Hospital, Sheffield, UK
Address correspondence to Dr S. Goodacre, Medical Care Research Unit, University of Sheffield, Regent Court, 30 Regent Street, Sheffield, S1 4DA. email: s.goodacre{at}sheffield.ac.uk
Received 21 February 2006 and in revised form 21 March 2006
Background: Many different approaches are used to diagnose suspected deep-vein thrombosis (DVT), but there has been little formal comparison of strategies.
Aim: To identify the most cost-effective strategy for the UK National Health Service (NHS).
Design: Systematic review, meta-analysis and cost-effectiveness analysis.
Methods: We identified 18 strategies and estimated the diagnostic performance of constituent tests by systematic review and meta-analysis. Outcomes of testing and treatment were estimated from published data or by an expert panel. Costs were estimated from NHS reference costs and published data. We built a decision-analysis model to estimate, for each strategy, the overall accuracy, costs, and outcomes (valued as quality-adjusted life-years, QALYs), compared to a 'no testing, no treatment' alternative. Probabilistic analysis estimated the net benefit of each strategy at varying thresholds for willingness to pay for health gain.
Results: At the thresholds for willingness to pay recommended by the National Institute for Clinical Excellence (£20 000–£30 000 per QALY), the optimal strategy was to discharge patients with a low or intermediate Wells score and negative D-dimer, limiting ultrasound to those with a high score or positive D-dimer. Strategies using radiological testing for all patients were only cost-effective at £40 000 per QALY or more.
Discussion: The optimal strategy for DVT diagnosis is to use ultrasound selectively in patients with a high clinical risk or positive D-dimer. Radiological testing for all patients does not appear to be a cost-effective use of health service resources.
Steve Goodacre, UK Department of Health. This article is covered by Crown Copyright as a part of the funding contract between the University of Sheffield (Principal Investigator: Steve Goodacre) and the UK Department of Health.
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