Cargando…

Accuracy of Practitioner Estimates of Probability of Diagnosis Before and After Testing

IMPORTANCE: Accurate diagnosis is essential to proper patient care. OBJECTIVE: To explore practitioner understanding of diagnostic reasoning. DESIGN, SETTING, AND PARTICIPANTS: In this survey study, 723 practitioners at outpatient clinics in 8 US states were asked to estimate the probability of dise...

Descripción completa

Detalles Bibliográficos
Autores principales: Morgan, Daniel J., Pineles, Lisa, Owczarzak, Jill, Magder, Larry, Scherer, Laura, Brown, Jessica P., Pfeiffer, Chris, Terndrup, Chris, Leykum, Luci, Feldstein, David, Foy, Andrew, Stevens, Deborah, Koch, Christina, Masnick, Max, Weisenberg, Scott, Korenstein, Deborah
Formato: Online Artículo Texto
Lenguaje:English
Publicado: American Medical Association 2021
Materias:
Acceso en línea:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8022260/
https://www.ncbi.nlm.nih.gov/pubmed/33818595
http://dx.doi.org/10.1001/jamainternmed.2021.0269
_version_ 1783674902507683840
author Morgan, Daniel J.
Pineles, Lisa
Owczarzak, Jill
Magder, Larry
Scherer, Laura
Brown, Jessica P.
Pfeiffer, Chris
Terndrup, Chris
Leykum, Luci
Feldstein, David
Foy, Andrew
Stevens, Deborah
Koch, Christina
Masnick, Max
Weisenberg, Scott
Korenstein, Deborah
author_facet Morgan, Daniel J.
Pineles, Lisa
Owczarzak, Jill
Magder, Larry
Scherer, Laura
Brown, Jessica P.
Pfeiffer, Chris
Terndrup, Chris
Leykum, Luci
Feldstein, David
Foy, Andrew
Stevens, Deborah
Koch, Christina
Masnick, Max
Weisenberg, Scott
Korenstein, Deborah
author_sort Morgan, Daniel J.
collection PubMed
description IMPORTANCE: Accurate diagnosis is essential to proper patient care. OBJECTIVE: To explore practitioner understanding of diagnostic reasoning. DESIGN, SETTING, AND PARTICIPANTS: In this survey study, 723 practitioners at outpatient clinics in 8 US states were asked to estimate the probability of disease for 4 scenarios common in primary care (pneumonia, cardiac ischemia, breast cancer screening, and urinary tract infection) and the association of positive and negative test results with disease probability from June 1, 2018, to November 26, 2019. Of these practitioners, 585 responded to the survey, and 553 answered all of the questions. An expert panel developed the survey and determined correct responses based on literature review. RESULTS: A total of 553 (290 resident physicians, 202 attending physicians, and 61 nurse practitioners and physician assistants) of 723 practitioners (76.5%) fully completed the survey (median age, 32 years; interquartile range, 29-44 years; 293 female [53.0%]; 296 [53.5%] White). Pretest probability was overestimated in all scenarios. Probabilities of disease after positive results were overestimated as follows: pneumonia after positive radiology results, 95% (evidence range, 46%-65%; comparison P < .001); breast cancer after positive mammography results, 50% (evidence range, 3%-9%; P < .001); cardiac ischemia after positive stress test result, 70% (evidence range, 2%-11%; P < .001); and urinary tract infection after positive urine culture result, 80% (evidence range, 0%-8.3%; P < .001). Overestimates of probability of disease with negative results were also observed as follows: pneumonia after negative radiography results, 50% (evidence range, 10%-19%; P < .001); breast cancer after negative mammography results, 5% (evidence range, <0.05%; P < .001); cardiac ischemia after negative stress test result, 5% (evidence range, 0.43%-2.5%; P < .001); and urinary tract infection after negative urine culture result, 5% (evidence range, 0%-0.11%; P < .001). Probability adjustments in response to test results varied from accurate to overestimates of risk by type of test (imputed median positive and negative likelihood ratios [LRs] for practitioners for chest radiography for pneumonia: positive LR, 4.8; evidence, 2.6; negative LR, 0.3; evidence, 0.3; mammography for breast cancer: positive LR, 44.3; evidence range, 13.0-33.0; negative LR, 1.0; evidence range, 0.05-0.24; exercise stress test for cardiac ischemia: positive LR, 21.0; evidence range, 2.0-2.7; negative LR, 0.6; evidence range, 0.5-0.6; urine culture for urinary tract infection: positive LR, 9.0; evidence, 9.0; negative LR, 0.1; evidence, 0.1). CONCLUSIONS AND RELEVANCE: This survey study suggests that for common diseases and tests, practitioners overestimate the probability of disease before and after testing. Pretest probability was overestimated in all scenarios, whereas adjustment in probability after a positive or negative result varied by test. Widespread overestimates of the probability of disease likely contribute to overdiagnosis and overuse.
format Online
Article
Text
id pubmed-8022260
institution National Center for Biotechnology Information
language English
publishDate 2021
publisher American Medical Association
record_format MEDLINE/PubMed
spelling pubmed-80222602021-04-21 Accuracy of Practitioner Estimates of Probability of Diagnosis Before and After Testing Morgan, Daniel J. Pineles, Lisa Owczarzak, Jill Magder, Larry Scherer, Laura Brown, Jessica P. Pfeiffer, Chris Terndrup, Chris Leykum, Luci Feldstein, David Foy, Andrew Stevens, Deborah Koch, Christina Masnick, Max Weisenberg, Scott Korenstein, Deborah JAMA Intern Med Original Investigation IMPORTANCE: Accurate diagnosis is essential to proper patient care. OBJECTIVE: To explore practitioner understanding of diagnostic reasoning. DESIGN, SETTING, AND PARTICIPANTS: In this survey study, 723 practitioners at outpatient clinics in 8 US states were asked to estimate the probability of disease for 4 scenarios common in primary care (pneumonia, cardiac ischemia, breast cancer screening, and urinary tract infection) and the association of positive and negative test results with disease probability from June 1, 2018, to November 26, 2019. Of these practitioners, 585 responded to the survey, and 553 answered all of the questions. An expert panel developed the survey and determined correct responses based on literature review. RESULTS: A total of 553 (290 resident physicians, 202 attending physicians, and 61 nurse practitioners and physician assistants) of 723 practitioners (76.5%) fully completed the survey (median age, 32 years; interquartile range, 29-44 years; 293 female [53.0%]; 296 [53.5%] White). Pretest probability was overestimated in all scenarios. Probabilities of disease after positive results were overestimated as follows: pneumonia after positive radiology results, 95% (evidence range, 46%-65%; comparison P < .001); breast cancer after positive mammography results, 50% (evidence range, 3%-9%; P < .001); cardiac ischemia after positive stress test result, 70% (evidence range, 2%-11%; P < .001); and urinary tract infection after positive urine culture result, 80% (evidence range, 0%-8.3%; P < .001). Overestimates of probability of disease with negative results were also observed as follows: pneumonia after negative radiography results, 50% (evidence range, 10%-19%; P < .001); breast cancer after negative mammography results, 5% (evidence range, <0.05%; P < .001); cardiac ischemia after negative stress test result, 5% (evidence range, 0.43%-2.5%; P < .001); and urinary tract infection after negative urine culture result, 5% (evidence range, 0%-0.11%; P < .001). Probability adjustments in response to test results varied from accurate to overestimates of risk by type of test (imputed median positive and negative likelihood ratios [LRs] for practitioners for chest radiography for pneumonia: positive LR, 4.8; evidence, 2.6; negative LR, 0.3; evidence, 0.3; mammography for breast cancer: positive LR, 44.3; evidence range, 13.0-33.0; negative LR, 1.0; evidence range, 0.05-0.24; exercise stress test for cardiac ischemia: positive LR, 21.0; evidence range, 2.0-2.7; negative LR, 0.6; evidence range, 0.5-0.6; urine culture for urinary tract infection: positive LR, 9.0; evidence, 9.0; negative LR, 0.1; evidence, 0.1). CONCLUSIONS AND RELEVANCE: This survey study suggests that for common diseases and tests, practitioners overestimate the probability of disease before and after testing. Pretest probability was overestimated in all scenarios, whereas adjustment in probability after a positive or negative result varied by test. Widespread overestimates of the probability of disease likely contribute to overdiagnosis and overuse. American Medical Association 2021-04-05 2021-06 /pmc/articles/PMC8022260/ /pubmed/33818595 http://dx.doi.org/10.1001/jamainternmed.2021.0269 Text en Copyright 2021 Morgan DJ et al. JAMA Internal Medicine. https://creativecommons.org/licenses/by/4.0/This is an open access article distributed under the terms of the CC-BY License.
spellingShingle Original Investigation
Morgan, Daniel J.
Pineles, Lisa
Owczarzak, Jill
Magder, Larry
Scherer, Laura
Brown, Jessica P.
Pfeiffer, Chris
Terndrup, Chris
Leykum, Luci
Feldstein, David
Foy, Andrew
Stevens, Deborah
Koch, Christina
Masnick, Max
Weisenberg, Scott
Korenstein, Deborah
Accuracy of Practitioner Estimates of Probability of Diagnosis Before and After Testing
title Accuracy of Practitioner Estimates of Probability of Diagnosis Before and After Testing
title_full Accuracy of Practitioner Estimates of Probability of Diagnosis Before and After Testing
title_fullStr Accuracy of Practitioner Estimates of Probability of Diagnosis Before and After Testing
title_full_unstemmed Accuracy of Practitioner Estimates of Probability of Diagnosis Before and After Testing
title_short Accuracy of Practitioner Estimates of Probability of Diagnosis Before and After Testing
title_sort accuracy of practitioner estimates of probability of diagnosis before and after testing
topic Original Investigation
url https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8022260/
https://www.ncbi.nlm.nih.gov/pubmed/33818595
http://dx.doi.org/10.1001/jamainternmed.2021.0269
work_keys_str_mv AT morgandanielj accuracyofpractitionerestimatesofprobabilityofdiagnosisbeforeandaftertesting
AT pineleslisa accuracyofpractitionerestimatesofprobabilityofdiagnosisbeforeandaftertesting
AT owczarzakjill accuracyofpractitionerestimatesofprobabilityofdiagnosisbeforeandaftertesting
AT magderlarry accuracyofpractitionerestimatesofprobabilityofdiagnosisbeforeandaftertesting
AT schererlaura accuracyofpractitionerestimatesofprobabilityofdiagnosisbeforeandaftertesting
AT brownjessicap accuracyofpractitionerestimatesofprobabilityofdiagnosisbeforeandaftertesting
AT pfeifferchris accuracyofpractitionerestimatesofprobabilityofdiagnosisbeforeandaftertesting
AT terndrupchris accuracyofpractitionerestimatesofprobabilityofdiagnosisbeforeandaftertesting
AT leykumluci accuracyofpractitionerestimatesofprobabilityofdiagnosisbeforeandaftertesting
AT feldsteindavid accuracyofpractitionerestimatesofprobabilityofdiagnosisbeforeandaftertesting
AT foyandrew accuracyofpractitionerestimatesofprobabilityofdiagnosisbeforeandaftertesting
AT stevensdeborah accuracyofpractitionerestimatesofprobabilityofdiagnosisbeforeandaftertesting
AT kochchristina accuracyofpractitionerestimatesofprobabilityofdiagnosisbeforeandaftertesting
AT masnickmax accuracyofpractitionerestimatesofprobabilityofdiagnosisbeforeandaftertesting
AT weisenbergscott accuracyofpractitionerestimatesofprobabilityofdiagnosisbeforeandaftertesting
AT korensteindeborah accuracyofpractitionerestimatesofprobabilityofdiagnosisbeforeandaftertesting