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PART 1—INDICATIONS FOR TESTING

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Diagnostic testing is used to evaluate symptoms or abnormal physical examination findings. Testing should be ordered to assess the severity or stability of a medical problem or to evaluate an abnormal symptom or sign detected during a medical interview and examination. Routine testing or repeated testing of asymptomatic individuals with previously normal test results does not accurately predict which patients will develop complications but it does increase resource use and healthcare costs.

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What are examples of appropriate testing?

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  • Screening for conditions associated with long-term morbidity or mortality

  • Identifying objective signs of improvement or progression of chronic disease

  • Monitoring levels of potentially toxic medications in the preoperative period (e.g., warfarin, digoxin)

  • Detecting drug-induced organ damage

  • Confirming the accuracy of previously obtained abnormal results

  • Pursuing a differential diagnosis of acute complaints, such as dyspnea or chest pain

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What are inappropriate rationales for diagnostic testing?

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  • Testing asymptomatic or low-risk patients

  • Repeating normal tests

  • Ordering screening tests with poor sensitivity

  • Ordering nonspecific batteries of tests that are unlikely to benefit patients

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What is case finding? How is it different from case confirming?

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  • The term case finding refers to routine ordering of tests to detect unsuspected disease. Case finding generally does not significantly improve morbidity or mortality and is not an appropriate rationale for hospital testing.

  • Case confirming refers to testing patients for suspected disease or screening asymptomatic patients for diseases of public health importance.

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CASE 11-1

You start your morning shift and have two patients handed over by the night shift. Both patients had chest pain during the night and negative troponins and EKGs.

Patient #1: Kelly is a 35-year-old morbidly obese woman with no pertinent past medical history admitted for intractable headaches. A review of systems is positive for burning, nonradiating substernal pain, which is worse at night and is unrelated to exertion. The burning sensation is not associated with nausea or diaphoresis and generally resolves on its own after several hours. Kelly is a non-smoker and has no contributory family history. Her serum total cholesterol level is 130 mg/dL. The pain during previous night was consistent with this past history.

Patient #2: Jack is an obese 65-year old man admitted for stroke. Jack has arterial hypertension, type 2 diabetes mellitus, dyslipidemia, and smokes cigarettes. He reports having occasional substernal chest pressure associated with dyspnea when he walks “faster than usual.” He developed chest pain last night while he was trying to get out of the bed and go to the bathroom.

You are considering referring each patient to the cardiology service for further testing. You speak to the cardiologist on the phone and inquire whether testing would be mandated in each case. She tells you that it depends on pretest probabilities because exercise stress testing is an imperfect test and has a sensitivity of 90% and a ...

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