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PubMed2004

Fatigue models as practical tools: diagnostic accuracy and decision thresholds.

Human fatigue models are increasingly being used in a variety of industrial settings, both civilian and military. Current uses include education, awareness, and analysis of individual or group work schedules. Perhaps the ultimate and potentially most beneficial use of human fatigue models is to diagnose if an individual is sufficiently rested to perform a period of duty safely or effectively. When used in this way, two important questions should be asked: 1) What is the accuracy of the diagnosis for duty-specific performance in this application; and 2) What decision threshold is appropriate for this application (i.e., how "fatigued" does an individual have to be to be considered "not safe"). In the simplest situation, a diagnostic fatigue test must distinguish between two states: "fatigued" and "not fatigued," and the diagnostic decisions are "safe" (or "effective") and "not safe" (or "not effective"). The resulting four decision outcomes include diagnostic errors because diagnostic tests are not perfectly accurate. Moreover, since all outcomes have costs and benefits associated with them that differ between applications, the choice of a decision criterion is extremely important. Signal Detection Theory (SDT) has demonstrated usefulness in measuring the accuracy of diagnostic tests and optimizing diagnostic decisions. This paper describes how SDT can be applied to foster the development of fatigue models as practical diagnostic and decision-making tools. By clarifying the difference between accuracy (or sensitivity) and decision criterion (or bias) in the use of fatigue models as diagnostic and decision-making tools, the SDT framework focuses on such critical issues as duty-specific performance, variability (model and performance), and model sensitivity, efficacy, and utility. As fatigue models become increasingly used in a variety of different applications, it is important that end-users understand the interplay of these factors for their particular application.

Decision Support Techniques↗
PubMed2001

[Abdominal pain and bowel dysfunction: diagnostic flow-chart could be simplified?].

BACKGROUND: The aim of the study was to evaluate the diagnostic role of Kruis score and intestinal ultrasound in young patients with abdominal pain and bowel dysfunction. METHODS: Prospective, double blind, case-control study in 297 consecutive patients with Crohn's disease and irritable bowel syndrome (from 1993 to 1995). INCLUSION CRITERIA: abdominal pain, bowel dysfunction without clear symptoms or signs of organic disease. The final diagnosis is obtained with usual diagnostic criteria and confirmed by at least 2 years of follow-up. Intestinal ultrasound is considered diagnostic of Crohn's disease if bowel wall thickness is = or > 7 mm; the Kruis score is diagnostic for irritable bowel syndrome if = or > 44. RESULTS: To diagnose Crohn's disease, intestinal ultrasound and Kruis score respectively showed sensitivity of 84 and 97%, specificity of 98 and 50%, positive predictive value of 91 and 33%, negative predictive value of 96 and 98%, efficacy of 95 and 60%. Both exams suggest the same diagnosis in 55% of patients with a correct diagnosis of 97%. CONCLUSIONS: The intestinal ultrasound and the Kruis score can be a good diagnostic association in young patients with abdominal pain and bowel dysfunction but without clear symptoms or signs of organic disease. If their diagnostic conclusions are the same (55%), they have a low probability of diagnostic error (3%). If they show a different diagnostic hypothesis, other markers of disease, for example ASCA, can be used.

English Abstract↗
PubMed1991

Diagnostic aspects of depression.

In this review the traditional concepts of endogenous depression and modern trials of classification in operationalized diagnostic systems, especially in DSM and ICD, are critically discussed. The psychopathological and other phenomenological symptomatologies of endogenous (cyclothymic) depression within monopolar and bipolar affective psychoses and the diagnosis and differential diagnosis above all against schizophrenia, organic brain diseases and psychoreactive disorders, are described. The possibilities and limitations of operationalized classifications with regard to diagnostic reliability and validity are presented. At present state of research homogeneous groups of patients with regard to affective and other idiopathic psychoses and here depressive syndromes and episodes cannot be defined, neither with the traditional concepts nor with the up to now available operationalized diagnostic classifications. In contemporary operationalized diagnostic systems among others the psychopathological and other phenomenological criteria are not sufficiently or too vaguely defined, the different significance of the requested inclusion-criteria and the intraindividual variability with regard to single episodes and subsequent phases of the depression are too little considered. Up to now all trials failed to validate different diagnostic concepts of depression by biological markers. Clinical psychopathological diagnosis of endogenous depression according to the traditional psychiatry criteria may reach a better validity under certain conditions than diagnoses according to DSM-III-R or ICD 10. To use exclusively operationalized diagnostic systems instead of clinical diagnosis in the diagnostic practice but also in research would be too early at present. Modern diagnostic systems can complete the clinical diagnosis but not replace it.

Affective Disorders, Psychotic↗
PubMed1988

Value of diagnostic laparoscopy in young women with possible appendicitis.

Removal of a normal appendix because of suspected appendicitis occurs most frequently in women of reproductive age. We investigated the value of laparoscopy in the diagnostic evaluation for possible appendicitis in women of childbearing age. Fifty-one women were entered in a management protocol, which included diagnostic laparoscopy in instances with atypical features. Twenty patients underwent immediate appendectomy because of history and physical findings classical for appendicitis; 31 women with atypical history and physical findings underwent an initial diagnostic laparoscopy. In the group of patients who underwent immediate appendectomy because of classical presentation, five of the appendices removed were normal. At laparoscopy, appendicitis was diagnosed in five patients, another disease in 15 and no diagnostic abnormality was found in six. Five patients had a normal appendix removed, two because of questionable inflammation and three because of nonvisualization of the appendix. There were no false-negative examination results. Twenty-one patients required no further operative intervention after laparoscopy. The negative appendectomy rate remained unchanged (ten negative appendectomies of 30 performed). Definitive diagnoses of eight instances of pelvic inflammatory disease, six of ruptured ovarian cysts and one instance of ileitis of the small intestine were made earlier than would have been possible without diagnostic laparoscopy in this setting. Diagnostic laparoscopy permits earlier definitive diagnosis and prompt institution of appropriate therapy for disease of the female reproductive tract that simulates appendicitis. Caution is advised, however, when diagnostic laparoscopy is applied more frequently than right lower quadrant exploration in the management of probable appendicitis. The improvement in diagnostic accuracy may be offset by an increased number of negative appendectomies resulting from nonvisualization and false-positive inflammation.

Adult↗
PubMed1983

Interpretation of diagnostic data: 5. How to do it with simple maths.

The use of simple maths with the likelihood ratio strategy fits in nicely with our clinical views. By making the most out of the entire range of diagnostic test results (i.e., several levels, each with its own likelihood ratio, rather than a single cut-off point and a single ratio) and by permitting us to keep track of the likelihood that a patient has the target disorder at each point along the diagnostic sequence, this strategy allows us to place patients at an extremely high or an extremely low likelihood of disease. Thus, the numbers of patients with ultimately false-positive results (who suffer the slings of labelling and the arrows of needless therapy) and of those with ultimately false-negative results (who therefore miss their chance for diagnosis and, possibly, efficacious therapy) will be dramatically reduced. The following guidelines will be useful in interpreting signs, symptoms and laboratory tests with the likelihood ratio strategy: Seek out, and demand from the clinical or laboratory experts who ought to know, the likelihood ratios for key symptoms and signs, and several levels (rather than just the positive and negative results) of diagnostic test results. Identify, when feasible, the logical sequence of diagnostic tests. Estimate the pretest probability of disease for the patient, and, using either the nomogram or the conversion formulas, apply the likelihood ratio that corresponds to the first diagnostic test result. While remembering that the resulting post-test probability or odds from the first test becomes the pretest probability or odds for the next diagnostic test, repeat the process for all the pertinent symptoms, signs and laboratory studies that pertain to the target disorder. However, these combinations may not be independent, and convergent diagnostic tests, if treated as independent, will combine to overestimate the final post-test probability of disease. You are now far more sophisticated in interpreting diagnostic tests than most of your teachers. In the last part of our series we will show you some rather complex strategies that combine diagnosis and therapy, quantify our as yet nonquantified ideas about use, and require the use of at least a hand calculator.

Bayes Theorem↗
PubMed1994

Evaluation of new diagnostic technologies: bronchoalveolar lavage and the diagnosis of ventilator-associated pneumonia.

OBJECTIVE: To present criteria to aid intensive care workers in the assessment of diagnostic technologies, using the example of bronchoalveolar lavage for the evaluation of ventilator-associated pneumonia. DATA SOURCES: MEDLINE was used to search for articles published from 1969 to the present that concerned diagnostic tests, diagnostic technology, pneumonia, and critically ill patients. STUDY SELECTION: Clinical investigations, case control studies, case series, and experimental data on the use of bronchoalveolar lavage. Studies of diagnostic technology were also included. DATA EXTRACTION: We extracted relevant data in duplicate, independently. DATA SYNTHESIS: Diagnostic technology assessment should begin by establishing the capability of the technology under ideal or laboratory conditions, followed by an exploration of the range of possible uses as well as the accuracy of the test. Bronchoalveolar lavage is a well-established technology for the diagnosis of pneumonia in immunocompromised patients. Studies of the accuracy of bronchoalveolar lavage in ventilator-dependent but nonimmunocompromised patients have shown promising diagnostic accuracy. Accuracy, however, is insufficient for dissemination of a test; an evaluation of the impact of a test on management decisions and, most importantly, on patient outcome, is required. Investigators have not addressed the full impact of bronchoalveolar lavage, and, even if the test is accurate, there are reasons to doubt whether patients will be better off if the test becomes part of routine clinical practice. CONCLUSIONS: We present guidelines for the assessment of diagnostic technology, and apply them to bronchoalveolar lavage for the evaluation of ventilator-associated pneumonia. Bronchoalveolar lavage has been studied in both the laboratory and clinical setting, and the diagnostic sensitivity and specificity of this technique are high. Further randomized trials evaluating management decisions and patient benefit would facilitate decisions regarding the appropriate dissemination of bronchoalveolar lavage.

Bronchoalveolar Lavage Fluid↗
PubMed1993

Do diagnostic algorithms always produce a uniform lung scan interpretation?

Several algorithms have been devised to assist in the interpretation of ventilation-perfusion (V/Q) scans performed to diagnose pulmonary embolism. The degree to which adherence to a single algorithm facilitates diagnostic homogeneity among different readers, however, has been little investigated. We evaluated the individual variability in V/Q lung scan interpretation in a large, academic nuclear medicine division to determine the degree of interpretive heterogeneity among a group of physicians all using the same image interpretation algorithm. Ventilation-perfusion scan interpretive patterns and the diagnostic accuracy of individual physicians were evaluated using quantitative parameters to establish group norms and to detect variations from these norms. The performance of each reader was tracked over a 4 yr period. There was a significant variation in V/Q interpretive patterns and diagnostic accuracy between readers despite the attempted use of a uniform diagnostic algorithm. Subgroups of interpretive styles could be defined based on the percentage of intermediate (including both indeterminate and intermediate categories) scans read. Although there was significant variation in diagnostic accuracy among readers, there was no obvious correlation between accuracy and reading style except that the most nonstandard diagnostic patterns were associated with the most variable diagnostic accuracy. These data show a measurable variation in interpretive patterns and accuracy among multiple readers of V/Q scans despite attempted group adherence to an established diagnostic algorithm.

Algorithms↗
PubMed1995

Diagnostic and prognostic decision support systems.

Diagnostic decision support systems provide a quantitative evaluation of diagnostic evidence and the capability to combine diagnostic evidence in such a manner that a numeric measure of certainty in a final diagnostic recommendation results. Generally, expert systems serve to establish a diagnostic decision, inference networks allow a detailed analysis of the diagnostic value of diagnostic clues, case-based reasoning systems are designed to provide a prognostic assessment targeted to an individual patient. In all of these systems, symbolic information, i.e., traditional diagnostic, linguistic terms and concepts are processed and quantitatively evaluated.

Decision Support Techniques↗
PubMed1995

[Diagnostic value of ultrasonically guided lung aspiration in pneumonia].

To determine the diagnostic value of ultrasonic lung aspiration for patients with pneumonia, 60 patients with a tentative diagnosis of pneumonia were included in this study. After recording ultrasonographic findings, lung aspiration was done with a spinal needle and aspirated specimens were sent for Papanicolaou, May-Giemsa, acid fast, and Gram stains. The remaining specimens were sent for bacterial, mycobacterial and fungal culture. Twelve patients were excluded from the study because of the final diagnosis of non-infectious pulmonary diseases. In 28 cases of bacterial pneumonia, the diagnostic sensitivity of smear was 50% and culture 61%. The overall sensitivity of needle aspiration and culture was 71%. In 11 cases of bacterial pneumonia with a negative bacterial culture result, 7 cases were afebrile at the time of examination. To increase the diagnostic yield, needle aspiration should be performed at the acute stage of bacterial pneumonia. In 15 cases of pulmonary tuberculosis, the diagnostic rate of acid-fast smear was 47% and mycobacterial culture was 46%. The overall sensitivity of smear and culture was 60%. The diagnostic rate of needle biopsy was 75% and cytologic examination was 77%. Needle biopsy and cytologic examination enhanced the diagnostic rate of sputum-negative pulmonary tuberculosis. Cryptococcosis was documented by smear and needle biopsy in all of the five cases of cryptococcosis. Cryptococcosis is not easily detected by routine cytologic examination, and clinical information is still necessary to enhance the diagnostic rate. Our results show that ultrasonically guided lung aspiration is a technique with a high diagnostic yield and a low complication rate for various types of pneumonia. It is especially useful for patients without satisfactory clinical responses or without accurate microbiologic diagnosis.

Adult↗
PubMedDate not supplied

A diagnostic cluster system for skilled nursing facilities.

BACKGROUND AND OBJECTIVES: Diagnostic cluster systems have been developed to assist in analyzing diagnoses in outpatient and inpatient settings but not in convalescent hospital settings. We developed a diagnostic cluster system for skilled nursing facilities (SNFs) designed to include or capture a greater proportion of such diagnoses than a previously established inpatient diagnostic cluster system. METHODS: We tested the ability of the new SNF diagnostic cluster system to code diagnoses on records from SNFs in different geographic areas. Then we compared the proportion of admitting diagnoses captured by the new SNF diagnostic cluster system and by a previously established inpatient system. RESULTS: The new diagnostic cluster system captured between 92% and 96% of admitting diagnoses at the study SNFs. There was no statistically significant difference among the facilities in the proportion of diagnoses captured by the new system. By comparison, the previously established inpatient system captured only 59%-65% of these admitting diagnoses. The new system captured significantly more diagnoses than the previously established inpatient system. CONCLUSIONS: The new SNF diagnostic cluster system can be used to capture and code diagnostic data from SNFs.

Cluster Analysis↗
PubMed1998

Non-diagnostic smears in aspiration cytology of palpable breast lumps.

The cytologic diagnoses of a wide variety of breast diseases have been described in the literature and cytologic appearances of some of these are not characteristic. Technical problems during aspiration and smear preparation influence the final diagnosis, therefore, even at best hands a non-diagnostic category is to be expected. The objectives of this study were to determine the frequency of non-diagnostic reports and to assess the source of indecisiveness. This study is based on a retrospective analysis of breast aspirates signed out by the first author over a period of 18 months. The smears with non-diagnostic reports were correlated with the available histologic follow-up to identify the problem area. Forty-eight (9.1%) out of the 527 samples were non-diagnostic and within the recorded range of 6.9% to 20%. Of those 48 in the non-diagnostic category, 30 (62.5%) had histological follow-up. There were 11 (36.7%) malignant lesions and 19 (63.3%) benign lesions. In 23 cases (77%) pure interpretative problems and in 3 cases (10%) pure technical problems were responsible for the non-diagnostic reports. In 4 cases (13%) both factors contributed to the non-diagnostic report. Thirteen of the 30 (43%) lesions were cytologically suspected to be malignant. Of these 13.9 (69%) were found to be malignant while only 4 were benign; thus non-diagnostic but suspicious lesions are more likely to be malignant. The commonest cytologic features responsible for problems at interpretation were high cellularity (37%), cell discohesion (30%), large nuclei and nucleoli (30%) and the small size of the cells (40%). Inadequate or low cell yield (86%), inadequate clinical history (14%) and poor staining (14%) contributed to technical problems. The cytologic diagnosis of breast lesions such as fibromatosis, complex sclerosing lesions, papillary lesions, angiosarcoma and low nuclear grade in situ and invasive carcinomas can be difficult and the cytologic criteria for these diagnoses need further evaluation.

Biopsy, Needle↗
PubMed1998

[Sensitivity and specificity revisited: significance of the terms in analytic and diagnostic language].

Imprecise usage of the terms "sensitivity" and "specificity" produces confusion in the diagnostic use sophisticated laboratory test results. "Analytical sensitivity" represents the smallest amount of substance in a sample that can accurately be measured by an assay. "Analytical specificity refers to the ability of an assay to measure one particular organism or substance, rather than others, in a sample. An assay's analytical sensitivity and analytical specificity are distinct from that assay's clinical diagnostic sensitivity and diagnostic specificity. Diagnostic "sensitivity" is the percentage of persons who have a given disorder who are identified by the assay as positive for the disorder. High analytical sensitivity does not guarantee acceptable diagnostic sensitivity. "Diagnostic sensitivity" is the percentage of persons who do not have a given condition who are identified by the assay as negative for the condition. False-positive reactions occur because of sample contamination and diminish the diagnostic specificity of the assay. The terms "sensitivity" and "specificity" should be used with the requisite adjectives because the "diagnostic" and the "analytical" meanings of these terms are very different.

Diagnosis↗
PubMed2003

Towards complete and accurate reporting of studies of diagnostic accuracy: The STARD Initiative.

BACKGROUND: To comprehend the results of diagnostic accuracy studies, readers must understand the design, conduct, analysis, and results of such studies. That goal can be achieved only through complete transparency from authors. OBJECTIVE: To improve the accuracy and completeness of reporting of studies of diagnostic accuracy in order to allow readers to assess the potential for bias in the study and to evaluate its generalizability. METHODS: The Standards for Reporting of Diagnostic Accuracy (STARD) steering committee searched the literature to identify publications on the appropriate conduct and reporting of diagnostic studies and extracted potential items into an extensive list. Researchers, editors, methodologists and statisticians, and members of professional organizations shortened this list during a 2-day consensus meeting with the goal of developing a checklist and a generic flow diagram for studies of diagnostic accuracy. RESULTS: The search for published guidelines on diagnostic research yielded 33 previously published checklists, from which we extracted a list of 75 potential items. The consensus meeting shortened the list to 25 items, using evidence on bias whenever available. A prototypical flow diagram provides information about the method of patient recruitment, the order of test execution, and the numbers of patients undergoing the test under evaluation, the reference standard, or both. CONCLUSIONS: Evaluation of research depends on complete and accurate reporting. If medical journals adopt the checklist and the flow diagram, the quality of reporting of studies of diagnostic accuracy should improve to the advantage of the clinicians, researchers, reviewers, journals, and the public.

Algorithms↗
PubMed2005

Challenges in systematic reviews of diagnostic technologies.

Diagnostic tests are critical components of effective health care. They help determine treatments that are most beneficial for a given patient. Their assessment is a complex process that includes such challenges as a dearth of studies that evaluate clinical outcomes and lack of data on use of the test in realistic clinical settings. The methodologic quality of studies of diagnostic tests also lags behind the quality of studies of therapeutic interventions. Statistical methods to combine diagnostic accuracy data are more complex and not as well developed, leading to difficulties in the interpretation of results. The Agency for Healthcare Research and Quality Technology Assessment Program has adopted a 6-level framework for evaluating diagnostic technologies. The model emphasizes the need for systematic reviews of diagnostic test studies to go beyond the assessment of technical feasibility and accuracy to examine the impact of the test on health outcomes. In this paper, we use examples from 3 Evidence-based Practice Center reports to illustrate 3 challenges reviewers may face when reviewing diagnostic test literature: finding relevant studies, assessing methodologic quality of diagnostic accuracy studies, and synthesizing studies that evaluate tests in different patient populations or use different outcomes.

Diagnostic Techniques and Procedures↗
PubMed2003

The additional diagnostic value of ultrasonography in the diagnosis of breast cancer.

BACKGROUND: The use of ultrasonography (US) in diagnostic breast imaging is increasing. Restricting US to subgroups of patients who benefit most would result in a more efficient and effective application. This study assessed the diagnostic value of US as an adjunct to mammography (MAM) and a clinical examination (CE) in the diagnosis of breast cancer and the feasibility of selecting subgroups of patients who benefit the most. METHODS: Between October 1, 1999, and August 1, 2000, all consecutive patients referred for breast imaging underwent additional US after MAM and a CE. Results were scored on a 5-point grading scale of increasing suggestion of malignancy. Pathologic results during 12 months of follow-up were used as the criterion standard. Receiver-operating characteristic curve analysis assessed the diagnostic value of US in the whole population and in subgroups of patients according to indication for referral and age. RESULTS: A total of 3835 breasts were examined in 2020 patients, with a 6.3% prevalence of breast cancer. Breast US detected 8 extra malignancies and correctly downgraded 332 cases from a positive to a negative diagnosis (ie, from a suggested malignancy to no malignancy). Receiver-operating characteristic curves showed a significant improvement in diagnostic value by adding US to MAM and a CE (area under the curve for CE + MAM + US vs CE + MAM, 0.99 vs 0.95; P =.002). The diagnostic yield improved significantly in patients referred for palpable breast lumps (P =.004) or referred from the National Breast Cancer Screening Program (P =.05). Less pronounced was the value in patients referred for other symptoms or for follow-up of a prior breast malignancy. When breast imaging of the contralateral breast or of asymptomatic patients referred for reassurance or follow-up of a prior benign lesion was performed, the value of additional US remained undefined because of the few malignancies found. CONCLUSIONS: The systematic application of breast US improved the overall diagnostic yield. The diagnostic value increased most in patients with palpable breast lumps and in patients referred with abnormal screening MAM results.

Adolescent↗
PubMed1996

How independent are multiple 'independent' diagnostic classifications?

Multiple performances of diagnostic tests are commonly employed in clinical practice and epidemiologic research to assess test reliability, to increase sensitivity or specificity, or to correct for misclassification bias. An assumption almost universally made in this context is the assumption of independence of test results conditional on the true value. For dichotomous diagnostic tests, for example, disease present or absent, this assumption is usually not tenable, however, since there is typically a continuum of the traits that underly diagnosis and individuals in the vicinity of the (implicit or explicit) diagnostic cutpoint (such as the threshold of clinical detectibility) are more likely to be misclassified than other individuals. This paper assesses the magnitude of the resulting correlation of diagnostic errors as a function of the distribution of the underlying trait, the magnitude of the measurement error and the diagnostic threshold. It is concluded that errors of diagnostic tests can be strongly correlated even if errors in perception of the underlying trait are independent. It is illustrated by numerical examples that such positive correlation of diagnostic errors can substantially inflate commonly employed indices of reliability, such as the kappa coefficient.

Bias↗
PubMed2004

GEE approaches to marginal regression models for medical diagnostic tests.

The evaluation of a new medical diagnostic test may focus on two different scientific questions: (1). The new test may replace an existing one because of lower cost or higher validity. A related question would be the selection of the 'best' test(s) from a bundle of new or established measurements. (2). The new test may be used supplementary to other new or established procedures. In a recent publication, Leisenring and co-workers (Stat Med 1997; 16:1263-1281) developed a general marginal regression model for comparisons of diagnostic tests focussing on question (1). i.e. on the selection of the 'best' procedure. They applied the GEE approach of Liang and Zeger (Biometrika 1987; 73:13-22) to adjust for the correlation of data as a nuisance parameter. Using the general framework provided by Leisenring et al., we extend their approach and apply the GEE methodology to question (2). i.e. to the investigation of which of several diagnostic tests should be used supplementary to each other. We analyse data from a longitudinal study concerning pathogenesis, diagnosis and long-term course of the eye disease glaucoma. We find a dependence of the correlation structure of several diagnostic measurements on the severity of the disease. This result may be useful in clinical applications as regards the selection of subsets of diagnostic measurements in individual diagnostic processes but also in investigations concerning the relationship of the pathogenic process and the rationales of the different diagnostic procedures.

Biometry↗
PubMed1993

Diagnostic strategies in the management of acute upper gastrointestinal bleeding: patient and physician preferences.

BACKGROUND: Routine diagnostic endoscopy is commonly obtained for low-risk patients with acute upper gastrointestinal bleeding despite evidence from controlled trials that it does not improve patient outcome. OBJECTIVE: To determine whether endoscopy is being overutilized for these patients or whether considerations not addressed in the trials could justify its widespread use. METHODS: Twenty-five patients recovering from a recent hemorrhage and 22 primary care physicians used the analytic hierarchy process to perform an individualized analysis regarding the diagnostic management of acute upper gastrointestinal bleeding. The results were used to determine whether routine endoscopy was consistent with each subject's interpretation of relevant data and judgments regarding the relative importance of five management goals. The authors then compared the proportion of subjects in each group who preferred endoscopy over two non-endoscopy strategies (upper gastrointestinal series and no routine diagnostic test) with 85%, the current rate of endoscopy at the authors' hospital. RESULTS: Endoscopy was preferred by 92% (97.5% CI: 70%-98%) of the patients and 55% (97.5% CI: 31%-77%) of the physicians. The patients ranked identifying the cause of bleeding the second most important management goal after avoiding a poor outcome from the acute bleeding episode. CONCLUSIONS: The current rate of diagnostic endoscopy is higher than would be expected based on physicians' preferences but quite consistent with patients' preferences. Patients regard knowledge of the bleeding site as important, even if this information will not affect management or prognosis. Attempts to assess the use of diagnostic endoscopy and other diagnostic tests should take both patient preferences and the pure value of diagnostic information into account.

Adult↗