Dan, sorry if I am doing some disservice to your thoughtful note on diagnostic testing issues that you and the rest of us think "are extremely important to the use of EBM in the ongoing practice of medicine." However, I want to comment on one aspect of your note. I agree with you that the reasons for ordering the test can help clarify should the test be ordered or not, and how it should be interpreted. As you said, " For the care of an individual patient, we look for the therapeutic or diagnostic benefits to the patient as a result of the clinician being more certain about the diagnoses (and that leading to a change in therapy or prognosis)." In these situations, ordering a diagnostic test can be actually linked directly to the evidence on benefits and harms of treatment that we may have in mind. For example, several years ago we "played" with integration of various evidence-based medicine therapeutic summary measures within the context of simple clinical decision analysis in order to find out that a diagnostic test should never be ordered if the harm of treatment is greater than or equal to its benefit (see http://www.medscape.com/viewarticle/403613). That is, our decision about using DIAGNOSTIC tests (at bedside) are ultimately linked to our knowledge about our TREATMENTS. So, perhaps indeed we can develop "A hierarchical outcomes approach to test assessment" as advocated in the reference you cited.
best
ben
Benjamin Djulbegovic, MD,PhD
Professor of Oncology and Medicine
H. Lee Moffitt Cancer Center & Research Institute
at the University of South Florida
Department of Interdisciplinary Oncology
SRB #4, Floor 4, Rm #24031 (Rm# West 31)
12902 Magnolia Drive
Tampa, FL 33612
Editor: Cancer Treatment Reviews (Evidence-based Oncology Section)
http://www.harcourt-international.com/journals/ctrv/
e-mail:[log in to unmask]
http://www.hsc.usf.edu/~bdjulbeg/
phone:(813)979-7202
fax:(813)979-3071
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