- Research article
- Open Access
“Appropriate” diagnostic testing: supporting diagnostics with evidence-based medicine and shared decision making
© Polaris and Katz; licensee BioMed Central. 2014
- Received: 22 October 2014
- Accepted: 12 December 2014
- Published: 16 December 2014
Evidence-based medicine is an important approach to avoiding care that is unlikely to benefit patients in both the treatment and the diagnostic context. The medical evidence alone may not determine the most appropriate care decision. Patient interests are best served when the advantages and risks of a diagnostic test are viewed through the lens of the patient’s values. That is, the paradigm of evidence-based medicine should be complemented by the paradigm of shared decision making.
Diagnostic testing may offer physiological and psychological benefits. Clinicians should also discuss the potential harms, however, which may be physiological (e.g. radiation or scarring), psychological (e.g. anxiety), and financial (e.g. cost-sharing burdens). All three of these concerns are compounded by the risk of false positives or incidental findings that are not serious, but which require decisions about further testing or treatment.
We suggest that patient-centered decision making around diagnostic testing involves a two-step inquiry:
(1) Is the test medically appropriate? Does the available evidence documenting short- and long-term risk and benefits support the test for its intended use, given the patient’s characteristics and symptoms?
(2) Is the test appropriate for this patient? Has the provider initiated a conversation about tradeoffs that helps the patient evaluate whether the balance of risks and benefits is consonant with the patient’s own values and preferences? Potential benefits and harms to consider include the physiological, the psychological, and the financial.
- Shared decision making
- Patient-centered decision making
- Evidence-based medicine
- Diagnostic testing
The Excellence in Diagnostic Imaging Utilization Act of 2013 (H.R.3705) was introduced in the United States Congress in December of 2013. If passed, the Act would do three things: (1) direct professional medical societies to define standards of appropriate use for advanced diagnostic imaging technologies; (2) require practicing physicians to consult clinical decision support tools based on those standards (though not necessarily to follow the recommendations); and (3) establish data collection mechanisms on adherence to standards and usage of the decision support tools.
Like therapeutic interventions, diagnostic tests are sometimes ordered in cases where there is little likelihood of benefit to the patient, or where the expected benefits come with the risk of potential harms[1, 2]. The Act’s response is rooted in the tenets of evidence-based medicine, seeking to reduce medically unnecessary usage of diagnostic imaging in order to improve patient welfare and potentially also reduce costs. These same concerns apply more generally to other types of diagnostic testing, such as blood tests and biopsies.
Is the test medically appropriate? Does the available evidence documenting short- and long-term risk and benefits support the test for its intended use, given the patient’s characteristics and symptoms?
Is the test appropriate for this patient? Has the provider initiated a conversation about tradeoffs that helps the patient evaluate whether the balance of risks and benefits is consonant with the patient’s own values and preferences?
The Excellence in Diagnostic Imaging Utilization Act relies on the tenets of evidence-based medicine to address the stubborn problem of medically inappropriate diagnostic testing decisions. Shared decision making is much harder to mandate, however, since it does not depend on externally verifiable metrics like matching a diagnosis or biomarker to a recommended treatment. Clinical decision tools can include prompts for conversations about patient-centered outcomes and financial burden, but it is ultimately up to individual providers to elicit each patient’s values and preferences to help guide decisions.
To ensure appropriate diagnostic care decisions, clinicians should begin by asking what tests are appropriate in general for a patient with this set of characteristics and symptoms. Clinicians should then consider which test or other course of action is appropriate for this particular patient in light of her personal goals and preferences. Indeed, the process of deciding on a diagnostic test requires the same consideration and patience necessary for determining a medical diagnosis itself.
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