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The Wells rule was not useful in ruling out deep venous thrombosis in a primary care setting

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 Q In primary care patients with symptoms of deep venous thrombosis (DVT), how well does the Wells rule predict the presence or absence of DVT?

Clinical impact ratings GP/FP/Primary care ★★★★★☆☆ IM/Ambulatory care ★★★★★★☆ Internal medicine ★★★★★★☆ Haematology ★★★★★★☆ Emergency medicine ★★★★★☆☆


Embedded ImageDesign

a diagnostic rule developed by Wells et al in a secondary care setting was evaluated in primary care patients.

Embedded ImageSetting

primary care practices of 110 physicians in the Netherlands.

Embedded ImagePatients

1295 patients >18 years of age (mean age 60 y, 64% women), who visited their primary care physician with symptoms of swelling, redness, or pain in the legs for ⩽30 days and were suspected to have DVT. Patients with suspected pulmonary embolism were excluded.

Embedded ImageDescription of prediction guide

the Wells rule consisted of a score of 0–8, obtained by summing the presence of 8 characteristics identified from patient history (active cancer, immobilisation of the leg, and recently bedridden) and physical examination (localised tenderness, whole leg or calf swelling, pitting oedema, and collateral superficial veins), adjusted by −2 if another diagnosis was as or more likely than DVT. A score ⩽0 indicated low risk, 1–2 indicated medium risk, and ⩾3 indicated high risk. A normal result on d-dimer testing (<500 ng/ml), combined with a low risk score on the Wells rule, indicated very low risk.

Embedded ImageOutcomes

sensitivity, specificity, negative predictive value (NPV), and negative likelihood ratio.


By the Wells rule, 39% of patients were categorised …

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  • For correspondence: Dr R Oudega, University Medical Center Utrecht, Utrecht, The Netherlands. r.oudega{at}

  • Sources of funding: Healthcare Research Foundation “Ijsselmond” and The Netherlands Organization for Scientific Research.