Reassurance after diagnostic testing with a low pretest probability of serious disease: systematic review and meta-analysis.

Rolfe A
Burton C

JAMA Intern Med. 2013 Mar 25;173(6):407-16. doi: 10.1001/jamainternmed.2013.2762. (Review)
PMID: 23440131

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Disciplines

Family Medicine (FM)/General Practice (GP)

Relevance - 7/7
Newsworthiness - 6/7
General Internal Medicine-Primary Care(US)

Relevance - 7/7
Newsworthiness - 6/7
Internal Medicine

Relevance - 6/7
Newsworthiness - 6/7
Public Health

Relevance - 6/7
Newsworthiness - 5/7

Abstract

IMPORTANCE: Diagnostic tests are often ordered by physicians in patients with a low pretest probability of disease to rule out conditions and reassure the patient.

OBJECTIVE: To study the effect of diagnostic tests on worry about illness, anxiety, symptom persistence, and subsequent use of health care resources in patients with a low pretest probability of serious illness.

EVIDENCE ACQUISITION: Systematic review and meta-analysis. We searched MEDLINE, the Cochrane Central Register of Controlled Trials, EMBASE, PsychINFO, CINAHL, and ProQuest Dissertations electronic databases through December 31, 2011, for eligible randomized controlled trials. We independently identified studies for inclusion and extracted the data. Disagreements were resolved by discussion. We performed meta-analysis if heterogeneity was low or moderate (I2 < 50%).

RESULTS: Fourteen randomized controlled trials that included 3828 patients met the inclusion criteria and were analyzed with outcomes categorized as short term (=3 months) or long term (>3 months). Three trials showed no overall effect of diagnostic tests on illness worry (odds ratio, 0.87 [95% CI, 0.55-1.39]), and 2 showed no effect on nonspecific anxiety (standardized mean difference, 0.06 [-0.16 to 0.28]). Ten trials showed no overall long-term effect on symptom persistence (odds ratio, 0.99 [95% CI, 0.85-1.15]). Eleven trials measured subsequent primary care visits. We observed a high level of heterogeneity among trials (I2 = 80%). Meta-analysis after exclusion of outliers suggested a small reduction in visits after investigation (odds ratio, 0.77 [95% CI, 0.62-0.96]).

CONCLUSIONS AND RELEVANCE: Diagnostic tests for symptoms with a low risk of serious illness do little to reassure patients, decrease their anxiety, or resolve their symptoms, although the tests may reduce further primary care visits. Further research is needed to maximize reassurance from medically necessary tests and to develop safe strategies for managing patients without testing when an abnormal result is unlikely.

Clinical Comments

Family Medicine (FM)/General Practice (GP)

This meta-analysis has some significant limitations. 8 of the 14 trials were for the same condition (dyspepsia) and the follow-up was anywhere from 3 weeks to 18 months. An interesting review but clearly more evidence is needed.

Family Medicine (FM)/General Practice (GP)

This meta-analysis/systematic review pulls together the impressive body of data on the subject. The bottom line: do diagnostic tests arrive at a diagnosis? If you are doing a test believing a negative test result will reassure a patient, well, your belief is wrong. I think doing many tests, leaving no stone unturned so to speak, is actually harmful in that it reinforces to a patient that when the right test is finally done, the diagnosis will be made. The exact opposite of reassurance.

General Internal Medicine-Primary Care(US)

A fascinating article that only captured a few studies to show that provider assumptions of patient reassurance with diagnostic testing may not be valid. The journal includes an editorial by Kroenke that highlights some strategies that providers might use to order diagnostic tests in a more judicious manner.

Internal Medicine

Worried patients are very common in my area of practice, and ordering tests is often the easiest way out. This study definitely has the potential to change clinical practice.

Public Health

Though this isn't new, it hasn't trickled down to practice as much as it should. We need to really understand this!

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