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A Retrospective Study of Adult and Pediatric D-Dimer Tests to Identify Opportunities for Improved Utilization
Rabab Al Dawood1,2, Hassan Abu Sabah1,3, Natalie Mathews1,4
1Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Canada.
Insights
D-dimer tests are commonly used for evaluating venous thromboembolic events (VTE) and disseminated intravascular coagulation (DIC) in both children and adults. Quality improvement is needed for better documentation and appropriate D-dimer test utilization.
Area of Science:
- Clinical Chemistry
- Hematology
- Diagnostic Medicine
Background:
- D-dimers, a marker of fibrinolysis, are utilized in diagnosing disseminated intravascular coagulation (DIC) and certain inflammatory conditions in children.
- In adults, D-dimer testing aids in evaluating DIC and, when combined with clinical probability, can help rule out venous thromboembolic events (VTE).
Purpose of the Study:
- To evaluate the current utilization of D-dimer testing in a hospital setting.
- To identify opportunities for improving the appropriate use of D-dimer assays and documentation of clinical scores.
Main Methods:
- A retrospective cohort study was conducted on patients undergoing D-dimer testing at Hamilton hospitals between June 2022 and May 2023.
- Data collected included patient demographics, reasons for testing, D-dimer levels, and documentation of VTE likelihood and DIC scores.
Main Results:
- D-dimer testing was performed on 175 children and 200 adults, with most tests ordered in emergency departments for suspected VTE or DIC.
- Elevated D-dimer levels were common (55% children, 61% adults), and VTE likelihood or DIC scores were infrequently documented.
- A significant portion of D-dimer workload (15%) involved patients with multiple tests, often for monitoring DIC.
Conclusions:
- The primary indications for D-dimer testing in both pediatric and adult populations were the assessment of VTE and DIC.
- There is a clear need for quality improvement initiatives to enhance the documentation of clinical scores and optimize D-dimer test utilization.
Introduction:
D-dimers are produced by lysis of cross-linked fibrin. In children, D-dimer testing is used to evaluate disseminated intravascular coagulation (DIC) and some inflammatory states, but its use is not validated for screening or ruling out suspected venous thromboembolic events (VTE). In adults, D-dimers are used to evaluate DIC, and a low D-dimer level is used to exclude VTE in patients when combined with a low or moderate probability of VTE.
Methods:
To assess D-dimer utilization and opportunities for improvement, we conducted a retrospective, consecutive-case cohort study (with ethics approval) of patients who had D-dimer tests at Hamilton hospitals, from 06/2022 to 05/2023.
Results:
D-dimer levels were evaluated for 175 children and 200 adults (respective results, children/adults: median ages: 12/63, ranges 0-17/18-94 years), and an overlapping cohort of 99 consecutive persons with ≥ 5 D-dimer determinations. Most patients had D-dimer tests in emergency departments (60%/62%) and elevated D-dimer levels (55%/61%). Reasons for D-dimer assessment included: suspected VTE (50%/70%), DIC (17%/3.5%), childhood inflammatory conditions (23%/0%), and "off-label" uses (e.g., arterial thrombosis assessment; 5%/22%). VTE likelihood and DIC scores were rarely documented. Patients with multiple tests accounted for 15% of D-dimer workload. Among patients with multiple tests for DIC, most had overt DIC on initial assessment, with declining D-dimer levels over 10-14 days, including patients who died.
Conclusion:
VTE and DIC assessment was the most common reason for D-dimer assessments for children and adults. Quality improvement initiatives are needed to improve relevant clinical VTE and DIC score documentation and D-dimer test utilization.
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