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dc.contributor.authorMorgan, Daniel J
dc.contributor.authorPineles, Lisa
dc.contributor.authorOwczarzak, Jill
dc.contributor.authorMagder, Larry
dc.contributor.authorScherer, Laura
dc.contributor.authorBrown, Jessica P
dc.contributor.authorPfeiffer, Chris
dc.contributor.authorTerndrup, Chris
dc.contributor.authorLeykum, Luci
dc.contributor.authorFeldstein, David
dc.contributor.authorFoy, Andrew
dc.contributor.authorStevens, Deborah
dc.contributor.authorKoch, Christina
dc.contributor.authorMasnick, Max
dc.contributor.authorWeisenberg, Scott
dc.contributor.authorKorenstein, Deborah
dc.date.accessioned2021-04-23T18:20:21Z
dc.date.available2021-04-23T18:20:21Z
dc.date.issued2021-04-05
dc.identifier.urihttp://hdl.handle.net/10713/15484
dc.description.abstractImportance: 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.en_US
dc.description.urihttps://doi.org/10.1001/jamainternmed.2021.0269en_US
dc.description.urihttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC8022260/en_US
dc.language.isoenen_US
dc.publisherAmerican Medical Associationen_US
dc.relation.ispartofJAMA Internal Medicineen_US
dc.subjectdiagnostic reasoningen_US
dc.subject.meshDiagnostic Tests, Routineen_US
dc.subject.meshGeneral Practionersen_US
dc.titleAccuracy of Practitioner Estimates of Probability of Diagnosis Before and After Testingen_US
dc.typeArticleen_US
dc.identifier.doi10.1001/jamainternmed.2021.0269
dc.identifier.pmid33818595
dc.identifier.eissn2168-6114
dc.source.countryUnited States


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