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How Much Overtesting Is Needed to Safely Exclude a Diagnosis? A Different Perspective on Triage Testing Using Bayes' Theorem

Ruling out disease often requires expensive or potentially harmful confirmation testing. For such testing, a less invasive triage test is often used. Intuitively, few negative confirmatory tests suggest success of this approach. However, if negative confirmation tests become too rare, too many disea...

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Autores principales: Sikkens, Jonne J., Beekman, Djoeke G., Thijs, Abel, Bossuyt, Patrick M., Smulders, Yvo M.
Formato: Online Artículo Texto
Lenguaje:English
Publicado: Public Library of Science 2016
Materias:
Acceso en línea:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4777363/
https://www.ncbi.nlm.nih.gov/pubmed/26939066
http://dx.doi.org/10.1371/journal.pone.0150891
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author Sikkens, Jonne J.
Beekman, Djoeke G.
Thijs, Abel
Bossuyt, Patrick M.
Smulders, Yvo M.
author_facet Sikkens, Jonne J.
Beekman, Djoeke G.
Thijs, Abel
Bossuyt, Patrick M.
Smulders, Yvo M.
author_sort Sikkens, Jonne J.
collection PubMed
description Ruling out disease often requires expensive or potentially harmful confirmation testing. For such testing, a less invasive triage test is often used. Intuitively, few negative confirmatory tests suggest success of this approach. However, if negative confirmation tests become too rare, too many disease cases could have been missed. It is therefore important to know how many negative tests are needed to safely exclude a diagnosis. We quantified this relationship using Bayes’ theorem, and applied this to the example of pulmonary embolism (PE), for which triage is done with a Clinical Decision Rule (CDR) and D-dimer testing, and CT-angiography (CTA) is the confirmation test. For a maximum proportion of missed PEs of 1% in triage-negative patients, we calculate a 67% 'mandatory minimum' proportion of negative CTA scans. To achieve this, the proportion of patients with PE undergoing triage testing should be appropriately low, in this case no higher than 24%. Pre-test probability, triage test characteristics, the proportion of negative confirmation tests, and the number of missed diagnoses are mathematically entangled. The proportion of negative confirmation tests—not too high, but definitely not too low either—could be a quality benchmark for diagnostic processes.
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spelling pubmed-47773632016-03-10 How Much Overtesting Is Needed to Safely Exclude a Diagnosis? A Different Perspective on Triage Testing Using Bayes' Theorem Sikkens, Jonne J. Beekman, Djoeke G. Thijs, Abel Bossuyt, Patrick M. Smulders, Yvo M. PLoS One Research Article Ruling out disease often requires expensive or potentially harmful confirmation testing. For such testing, a less invasive triage test is often used. Intuitively, few negative confirmatory tests suggest success of this approach. However, if negative confirmation tests become too rare, too many disease cases could have been missed. It is therefore important to know how many negative tests are needed to safely exclude a diagnosis. We quantified this relationship using Bayes’ theorem, and applied this to the example of pulmonary embolism (PE), for which triage is done with a Clinical Decision Rule (CDR) and D-dimer testing, and CT-angiography (CTA) is the confirmation test. For a maximum proportion of missed PEs of 1% in triage-negative patients, we calculate a 67% 'mandatory minimum' proportion of negative CTA scans. To achieve this, the proportion of patients with PE undergoing triage testing should be appropriately low, in this case no higher than 24%. Pre-test probability, triage test characteristics, the proportion of negative confirmation tests, and the number of missed diagnoses are mathematically entangled. The proportion of negative confirmation tests—not too high, but definitely not too low either—could be a quality benchmark for diagnostic processes. Public Library of Science 2016-03-03 /pmc/articles/PMC4777363/ /pubmed/26939066 http://dx.doi.org/10.1371/journal.pone.0150891 Text en © 2016 Sikkens et al http://creativecommons.org/licenses/by/4.0/ This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0/) , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
spellingShingle Research Article
Sikkens, Jonne J.
Beekman, Djoeke G.
Thijs, Abel
Bossuyt, Patrick M.
Smulders, Yvo M.
How Much Overtesting Is Needed to Safely Exclude a Diagnosis? A Different Perspective on Triage Testing Using Bayes' Theorem
title How Much Overtesting Is Needed to Safely Exclude a Diagnosis? A Different Perspective on Triage Testing Using Bayes' Theorem
title_full How Much Overtesting Is Needed to Safely Exclude a Diagnosis? A Different Perspective on Triage Testing Using Bayes' Theorem
title_fullStr How Much Overtesting Is Needed to Safely Exclude a Diagnosis? A Different Perspective on Triage Testing Using Bayes' Theorem
title_full_unstemmed How Much Overtesting Is Needed to Safely Exclude a Diagnosis? A Different Perspective on Triage Testing Using Bayes' Theorem
title_short How Much Overtesting Is Needed to Safely Exclude a Diagnosis? A Different Perspective on Triage Testing Using Bayes' Theorem
title_sort how much overtesting is needed to safely exclude a diagnosis? a different perspective on triage testing using bayes' theorem
topic Research Article
url https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4777363/
https://www.ncbi.nlm.nih.gov/pubmed/26939066
http://dx.doi.org/10.1371/journal.pone.0150891
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