Comparison of 2-point and 3-point point-of-care ultrasound techniques for deep vein thrombosis at the emergency department: A meta-analysis

Ju Hyung Lee, Sun Hwa Lee, Seong Jong Yun, Ju Hyung Lee, Sun Hwa Lee, Seong Jong Yun

Abstract

Background: To our knowledge, so far, no studies have comprehensively examined the performance of 2-point and 3-point point-of-care compression ultrasound (POCUS) in the diagnosis of lower extremity deep vein thrombosis (DVT). The aim of this meta-analysis was to compare the performance of 2-point and 3-point POCUS techniques for the diagnosis of DVT and evaluate the false-negative rate of each POCUS method.

Methods: A computerized search of the PubMed, EMBASE, and Cochrane library databases was performed to identify relevant original articles. Bivariate modeling and hierarchical summary receiver operating characteristic modeling were performed to compare the diagnostic performance of 2-point and 3-point POCUS. The pooled proportions of the false-negative rate for each POCUS method were assessed using a DerSimonian-Laird random-effects model. Meta-regression analyses were performed according to the patient and study characteristics.

Results: Seventeen studies from 16 original articles were included (2-point, 1337 patients in 9 studies; 3-point, 1035 patients in 8 studies). Overall, 2-point POCUS had similar pooled sensitivity [0.91; 95% confidence interval (95% CI), 0.68-0.98; P = .86) and specificity (0.98; 95% CI, 0.96-0.99; P = .60) as 3-point POCUS (sensitivity, 0.90; 95% CI, 0.83-0.95 and specificity, 0.95; 95% CI, 0.83-0.99). The false-negative rates of 2-point (4.0%) and 3-point POCUS (4.1%) were almost similar. Meta-regression analysis showed that high sensitivity and specificity tended to be associated with an initial POCUS performer (including attending emergency physician > only resident) and separate POCUS training for DVT (trained > not reported), respectively.

Conclusion: Both 2-point and 3-point POCUS techniques showed excellent performance for the diagnosis of DVT. We recommend that POCUS-trained attending emergency physicians perform the initial 2-point POCUS to effectively and accurately diagnose DVT.

Conflict of interest statement

All authors declare that they have no conflicts of interest.

Figures

Figure 1
Figure 1
The study selection process for the meta-analysis. EP = emergency physician, POCUS = point-of-care ultrasound, US = ultrasound.
Figure 2
Figure 2
Grouped bar charts showing the risk of bias (left) and applicability concerns (right) for the 17 included studies, using the Quality Assessment of Diagnostic Accuracy Studies-2 domains.
Figure 3
Figure 3
Coupled forest plots for the pooled sensitivity and specificity of 2-point point-of-care ultrasound for the diagnosis of deep vein thrombosis. Dots in squares represent sensitivity and specificity. Horizontal lines represent the 95% confidence interval (CI) for each included study. The combined estimate (“Summary”) is based on the random-effects model and is indicated using diamonds. Corresponding heterogeneities (I2) with 95% CIs are provided in the bottom right corners: I2 = 100% × (Q – df)/Q, where Q is Cochran heterogeneity statistic and df is the degrees of freedom.
Figure 4
Figure 4
Hierarchical summary receiver operating characteristic (HSROC) curve for using 2-point point-of-care ultrasound for the diagnosis of deep vein thrombosis. The summary point (red box) indicates that the summary sensitivity was 0.84 (95% CI: 0.72–0.92) and the summary specificity was 0.91 (95% CI: 0.85–0.95). The 95% confidence region represents the 95% CIs of summary sensitivity and specificity, and the 95% prediction region represents the 95% CIs of sensitivity and specificity for each included study. The study estimates indicate the sensitivity and specificity estimated using the data from each study. The size of the marker is scaled according to the total number of patients in each study.
Figure 5
Figure 5
Coupled forest plots of pooled sensitivity and specificity of 3-point point-of-care ultrasound for the diagnosis of deep vein thrombosis. Dots in squares represent sensitivity and specificity. Horizontal lines represent the 95% confidence interval (CI) for each included study. The combined estimate (“Summary”) is based on the random-effects model and is indicated using diamonds. Corresponding heterogeneities (I2) with 95% CIs are provided in the bottom right corners.
Figure 6
Figure 6
Hierarchical summary receiver operating characteristic (HSROC) curve for using 3-point point-of-care ultrasound for the diagnosis of deep vein thrombosis. The summary point (red box) indicates that the summary sensitivity was 0.95 (95% CI: 0.75–0.99) and the summary specificity was 0.95 (95% CI: 0.85–0.98). The 95% confidence region represents the 95% CIs of summary sensitivity and specificity, and the 95% prediction region represents the 95% CI of sensitivity and specificity for each included study.
Figure 7
Figure 7
Forest plots of the false-negative rate of the 2-point point-of-care ultrasound for the diagnosis of deep vein thrombosis. Numbers are pooled estimates with 95% confidence intervals (95% CIs) in parentheses. Horizontal lines indicate 95% CIs, and the black box on each line indicates the standardized mean difference for each study. The black diamond at the bottom of the plot indicates the average effect size of the included studies.
Figure 8
Figure 8
Forest plots of the false-negative rate of the 3-point point-of-care ultrasound for the diagnosis of deep vein thrombosis. Numbers are pooled estimates with 95% confidence intervals (95% CIs) in parentheses. Horizontal lines indicate 95% CIs, and the black box on each line indicates the standardized mean difference for each study. The black diamond at the bottom of the plot indicates the average effect size of the included studies.

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Source: PubMed

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