What’s the true value of a diagnostic test?

Edition: March 2012 - Vol 20 Number 03
Article#: 3940
Author: Repertoire

Diagnostic tests can be a vital component of high-value healthcare, but only if their benefit, potential harm and costs are considered, say the authors of a recent article in the Annals of Internal Medicine, “Appropriate Use of Screening and Diagnostic Tests to Foster High-Value, Cost-Conscious Care.”

The American College of Physicians convened an ad hoc task force to consider the value of a variety of screening or diagnostic tests that they believed are commonly used in clinical situations in which they are unlikely to be of high value. To arrive at the list, they followed three principles:

  • First, diagnostic tests usually should not be performed if the results will not change management.

  • Second, when the pretest probability of disease is low, the likelihood of a false-positive test result is higher than the likelihood of a true-positive result. False-positive results are of concern because they often lead to further testing, which may be expensive and potentially harmful. They may also create anxiety for the patient and may lead to inappropriate treatment.

  • Third, the true cost of a test includes not only the cost of the test itself, but also the downstream costs incurred after the test was performed. For example, an exercise stress test in an asymptomatic patient may result in a false-positive finding, which leads to cardiac catheterization, with its attendant costs and risks, but with no proven benefit.

1. Repeating screening ultrasonography for abdominal aortic aneurysm following a negative study.

2. Performing coronary angiography in patients with chronic stable angina with well-controlled symptoms on medical therapy or who lack specific high-risk criteria on exercise testing.

3. Performing echocardiography in asymptomatic patients with innocent-sounding heart murmurs, most typically grade I–II/VI short systolic, midpeaking murmurs that are audible along the left sternal border.

4. Performing routine periodic echocardiography in asymptomatic patients with mild aortic stenosis more frequently than every 3–5 years.

5. Routinely repeating echocardiography in asymptomatic patients with mild mitral regurgitation and normal left ventricular size and function.

6. Obtaining electrocardiograms to screen for cardiac disease in patients at low to average risk for coronary artery disease.

7. Obtaining exercise electrocardiogram for screening in low-risk asymptomatic adults.

8. Performing an imaging stress test (echocardiographic or nuclear) as the initial diagnostic test in patients with known or suspected coronary artery disease who are able to exercise and have no resting electrocardiographic abnormalities that may interfere with interpretation of test results.

9. Measuring brain natriuretic peptide in the initial evaluation of patients with typical findings of heart failure.

10. Annual lipid screening for patients not receiving lipid-lowering drug or diet therapy in the absence of reasons for changing lipid profiles.

11. Using MRI rather than mammography as the breast-cancer-screening test of choice for average-risk women.

12. In asymptomatic women with previously treated breast cancer, performing follow-up complete blood counts, blood chemistry studies, tumor marker studies, chest radiography, or imaging studies other than appropriate breast imaging.

13. Performing dual-energy x-ray absorptiometry screening for osteoporosis in women younger than 65 years in the absence of risk factors.

14. Screening low-risk individuals for hepatitis B virus infection.

15. Screening for cervical cancer in low-risk women aged 65 years or older and in women who have had a total hysterectomy (uterus and cervix) for benign disease.

16. Screening for colorectal cancer in adults older than 75 years or in adults with a life expectancy of less than 10 years.

17. Repeating colonoscopy within 5 years of an index colonoscopy in asymptomatic patients found to have low-risk adenomas.

18. Screening for prostate cancer in men older than 75 years or with a life expectancy of less than 10 years.

19. Using CA-125 antigen levels to screen women for ovarian cancer in the absence of increased risk.

20. Performing imaging studies in patients with nonspecific low back pain.

21. Performing preoperative chest radiography in the absence of a clinical suspicion for intrathoracic pathology.

22. Ordering routine preoperative laboratory tests, including complete blood count, liver chemistry tests, and metabolic profiles, in otherwise healthy patients undergoing elective surgery.

23. Performing preoperative coagulation studies in patients without risk factors or predisposing conditions for bleeding and with a negative history of abnormal bleeding.

24. Performing serologic testing for suspected early Lyme disease.

25. Performing serologic testing for Lyme disease in patients with chronic nonspecific symptoms and no clinical evidence of disseminated Lyme disease.

26. Performing sinus imaging studies for patients with acute rhinosinusitis in the absence of predisposing factors for atypical microbial causes.

27. Performing imaging studies in patients with recurrent, classic migraine headache and normal findings on neurologic examination.

28. Performing brain imaging studies (CT or MRI) to evaluate simple syncope in patients with normal findings on neurologic examination.

29. Routinely performing echocardiography in the evaluation of syncope, unless the history, physical examination, and electrocardiogram do not provide a diagnosis, or underlying heart disease is suspected.

30. Performing predischarge chest radiography for hospitalized patients with community-acquired pneumonia who are making a satisfactory clinical recovery.

31. Obtaining CT scans in a patient with pneumonia that is confirmed by chest radiography in the absence of complicating clinical or radiographic features.

32. Performing imaging studies, rather than a high-sensitivity D-dimer measurement, as the initial diagnostic test in patients with low pretest probability of venous thromboembolism.

33. Measuring D-dimer rather than performing appropriate diagnostic imaging (extremity ultrasonography, CT angiography, or ventilation–perfusion scintigraphy), in patients with intermediate or high probability of venous thromboembolism.

34. Performing follow-up imaging studies for incidentally discovered pulmonary nodules less than or equal to 4 mm in low-risk individuals.

35. Monitoring patients with asthma or chronic obstructive pulmonary disease by using full pulmonary function testing that includes lung volumes and diffusing capacity, rather than spirometry alone (or peak expiratory flow rate monitoring in asthma).

36. Performing an antinuclear antibody test in patients with nonspecific symptoms, such as fatigue and myalgia, or in patients with fibromyalgia.

37. Screening for chronic obstructive pulmonary disease with spirometry in individuals without respiratory symptoms.

Source: Annals of Internal Medicine, 17 January 2012, Volume 156, No. 2, p. 148.