The physician's estimate of the probability that a patient has a particular disease is a principal factor in the determination of whether to withhold treatment, obtain more data by testing, or treat without subjecting the patient to the risks of further diagnostic tests. Using the concepts of decision analysis, we have derived expressions for two threshold probabilities involved in this choice: a "testing" threshold and a "test-treatment" threshold. Values can be assigned to these thresholds from data on the reliability and potential risks of the diagnostic test and the benefits and risks of a specific treatment. Treatment should be withheld if the probability of disease is smaller than the testing threshold, and treatment should be given without further testing if the probability of disease is greater than the test-treatment threshold. The test should be performed (with treatment depending on the test outcome) only if the probability of disease is between the two thresholds. The method exposes important principles of decision making and helps the clinician develop a rational, quantitative approach to the use of diagnostic tests.
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[Full Text]
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[Abstract]
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[Full Text]
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Farmer, E. R.
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[Full Text]
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[Abstract][Full Text]
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[Abstract][Full Text]
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[Full Text]
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105: 896-905
[Abstract][Full Text]
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[Abstract][Full Text]
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[Abstract][Full Text]
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100
: e68-e72
[Full Text]
Bloch, M., Mann, S., Pickering, T.
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131: 227-227
[Full Text]
Tsevat, J., Kotagal, U. R.
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153: 681-688
[Abstract][Full Text]
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[Full Text]
Bapat, B, Noorani, H, Cohen, Z, Berk, T, Mitri, A, Gallie, B, Pritzker, K, Gallinger, S, Detsky, A S
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[Abstract][Full Text]
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[Full Text]
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[Abstract][Full Text]
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152: 383-387
[Abstract][Full Text]
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18: 19-28
[Abstract]
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(1998). Expected-utility Perspectives on Defensive Testing: Torts, Tradeoffs, and Thresholds-- Is Defensive Medicine Defensible?. Med Decis Making
18: 29-31
Rovner, D. R.
(1998). Laboratory Testing May Not Glitter Like Gold. Med Decis Making
18: 32-33
Owens, D. K.
(1998). Defensive Diagnostic Testing--A Case of Stolen Utility?. Med Decis Making
18: 33-34
Lurie, J. D., Sox, H. C.
(1997). High on the Differential. NEJM
337: 1377-1381
[Full Text]
Hornberger, J. C., Best, J. H., Garrison, L. P. Jr.
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[Abstract]
Moons, K. G.M., Stijnen, T., Michel, B. C., Buller, H. R., Van Es, G.-A., Grobbee, D. E., Habbema, J. D. F.
(1997). Application of Treatment Thresholds to Diagnostic-test Evaluation: An Alternative to the Comparison of Areas under Receiver Operating Characteristic Curves. Med Decis Making
17: 447-454
[Abstract]
BERNSTEIN, J.
(1997). Current Concepts Review - Decision Analysis. JBJS
79: 1404-14
[Full Text]
Cher, D. J., Lenert, L. A.
(1997). Rapid Approximation of Confidence Intervals for Markov Process Decision Models: Applications in Decision Support Systems. J. Am. Med. Inform. Assoc.
4: 301-312
[Abstract][Full Text]
Owens, D. K., Shachter, R. D., Nease, R. F. JR
(1997). Representation and Analysis of Medical Decision Problems with Influence Diagrams. Med Decis Making
17: 241-262
[Abstract]
Cher, D. J, Lenert, L. A
(1997). Rapid Approximation of Confidence Intervals for Markov Process Decision Models: Applications in Decision Support Systems. J Am Med Inform Assoc
4: 301-312
[Abstract][Full Text]
Badgett, R. G., Lucey, C. R., Mulrow, C. D.
(1997). Can the Clinical Examination Diagnose Left-Sided Heart Failure in Adults?. JAMA
277: 1712-1719
[Abstract]
Kuntz, K. M., Polak, J. F., Whittemore, A. D., Skillman, J. J., Kent, K. C.
(1997). Duplex Ultrasound Criteria for the Identification of Carotid Stenosis Should Be Laboratory Specific. Stroke
28: 597-602
[Abstract][Full Text]
Bernstein, J.
(1997). Test-indication Curves. Med Decis Making
17: 103-106
[Abstract]
Phelps, C. E.
(1997). Good Technologies Gone Bad: How and Why the Cost-Effectiveness of a Medical Intervention Changes for Different Populations. Med Decis Making
17: 107-117
[Abstract]
(1997). Statement on Health Outcomes Research in Sleep Apnea THIS OFFICIAL STATEMENT WAS APPROVED BY THE ATS BOARD OF DIRECTORS, JUNE 1997. Am. J. Respir. Crit. Care Med.
157: 335-341
[Full Text]
Djulbegovic, B., Desoky, A. H.
(1996). Equation and Nomogram for Calculation of Testing and Treatment Thresholds. Med Decis Making
16: 198-199
Carpenter, A. F., Price, R. B., Gambino, R., Soloway, H., Woloshin, S., Schwartz, L. M., Van den Ende, J., Van Gompel, A., Benoit, V. F., Ross, J. M., Sox, H. C.
(1996). Clinical Problem-Solving: If at First You Don't Succeed. NEJM
334: 918-920
[Full Text]
Wasson, J. H., Sox, H. C.
(1996). Clinical Prediction Rules: Have They Come of Age?. JAMA
275: 641-642
[Abstract]
Glasziou, P. P, Irwig, L. M
(1995). An evidence based approach to individualising treatment. BMJ
311: 1356-1359
[Full Text]
Velanovich, V.
(1994). Bayesian Analysis in the Diagnostic Process. American Journal of Medical Quality
9: 158-161
[Abstract]
Thibault, G. E.
(1994). The Appropriate Degree of Diagnostic Certainty. NEJM
331: 1216-1220
[Full Text]
Taragin, M. I., Wildman, D., Trout, R.
(1994). Assessing Disease Prevalence from Inaccurate Test Results: Teaching an Old Dog New Tricks. Med Decis Making
14: 369-373
[Abstract]
Pauker, S. G., Kopelman, R. I.
(1993). When Going for the Gold Is Not an Option. NEJM
329: 1716-1719
[Full Text]
Pauker, S. G., Kopelman, R. I.
(1993). A Rewarding Pursuit of Certainty. NEJM
329: 1103-1107
[Full Text]
Redelmeier, D. A., Lorig, K.
(1993). Assessing the Clinical Importance of Symptomatic Improvements: An Illustration in Rheumatology. Arch Intern Med
153: 1337-1342
[Abstract]
Deneef, P., Kent, D. L.
(1993). Using Treatment-tradeoff Preferences to Select Diagnostic Strategies: Linking the ROC Curve to Threshold Analysis. Med Decis Making
13: 126-132
[Abstract]
Merz, J. F., Small, M. J., Fischbeck, P. S.
(1992). Measuring Decision Sensitivity: A Combined Monte Carlo - Logistic Regression Approach. Med Decis Making
12: 189-196
[Abstract]
Plasencia, C. M., Alderman, B. W., Baron, A. E., Rolfs, R. T., Boyko, E. J.
(1992). A Method to Describe Physician Decision Thresholds and Its Application in Examining the Diagnosis of Coronary Artery Disease Based on Exercise Treadmill Testing. Med Decis Making
12: 204-212
[Abstract]
Gruppen, L. D., Wolf, F. M., Billi, J. E.
(1991). Information Gathering and Integration as Sources of Error in Diagnostic Decision Making. Med Decis Making
11: 233-239
[Abstract]
Buchsbaum, D. G., Buchanan, R. G., Centor, R. M., Schnoll, S. H., Lawton, M. J.
(1991). Screening for Alcohol Abuse Using CAGE Scores and Likelihood Ratios. ANN INTERN MED
115: 774-777
[Abstract]
Sainfort, F.
(1991). Eualuation of Medical Technologies: A Generalized ROC Analysis. Med Decis Making
11: 208-220
[Abstract]
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