What white blood cell count should prompt antibiotic treatment in a febrile child? Tutorial on the importance of disease likelihood to the interpretation of diagnostic tests

被引:5
作者
Kohn, MA [1 ]
Newman, TB [1 ]
机构
[1] Univ Calif San Francisco, Dept Epidemiol & Biostat, San Francisco, CA 94143 USA
关键词
diagnosis; decision theory; receiver operating characteristic curve;
D O I
10.1177/02729890122062839
中图分类号
R19 [保健组织与事业(卫生事业管理)];
学科分类号
摘要
Most diagnostic tests are not dichotomous (negative or positive) but, rather, have a range of possible results (very negative to very positive). If the pretest probability of disease is high, the test result that prompts treatment should be any value that is even mildly positive. If the pretest probability of disease is low, the test result needed to justify treatment should be very positive. Simple decision rules that fix the cutpoint separating positive from negative test results do not take into account the individual patient's pretest probability of disease. Allowing the cutpoint to change with the pretest probability of disease increases the value of the test. This is primarily an issue when the pretest probability of disease varies widely between patients and depends on characteristics that are not measured by the test, It remains an issue for decision rules based on multiple test results if these rules fail to account for important determinants of patient-specific risk. This tutorial demonstrates how the value of a diagnostic test depends on the ability to vary the cutpoint, using as an example the white blood cell count in febrile children at risk for bacteremia.
引用
收藏
页码:479 / 489
页数:11
相关论文
共 17 条
[1]  
[Anonymous], 1988, CLIN CHEM
[2]   PRACTICE GUIDELINE FOR THE MANAGEMENT OF INFANTS AND CHILDREN 0 TO 36 MONTHS OF AGE WITH FEVER WITHOUT SOURCE [J].
BARAFF, LJ ;
BASS, JW ;
FLEISHER, GR ;
KLEIN, JO ;
MCCRACKEN, GH ;
POWELL, KR ;
SCHRIGER, DL .
ANNALS OF EMERGENCY MEDICINE, 1993, 22 (07) :1198-1210
[3]   USE OF THE INITIAL ELECTROCARDIOGRAM TO PREDICT IN-HOSPITAL COMPLICATIONS OF ACUTE MYOCARDIAL-INFARCTION [J].
BRUSH, JE ;
BRAND, DA ;
ACAMPORA, D ;
CHALMER, B ;
WACKERS, FJ .
NEW ENGLAND JOURNAL OF MEDICINE, 1985, 312 (18) :1137-1141
[4]   REDUCING UNNECESSARY CORONARY-CARE UNIT ADMISSIONS - A COMPARISON OF 3 DECISION AIDS [J].
DAVISON, G ;
SUCHMAN, AL ;
GOLDSTEIN, BJ .
JOURNAL OF GENERAL INTERNAL MEDICINE, 1990, 5 (06) :474-479
[5]   A MATHEMATICAL APPROACH TO INTERPRETATION AND SELECTION OF DIAGNOSTIC-TESTS [J].
DOUBILET, P .
MEDICAL DECISION MAKING, 1983, 3 (02) :177-195
[6]   A prediction rule to identify low-risk patients with community-acquired pneumonia [J].
Fine, MJ ;
Auble, TE ;
Yealy, DM ;
Hanusa, BH ;
Weissfeld, LA ;
Singer, DE ;
Coley, CM ;
Marrie, TJ ;
Kapoor, WN .
NEW ENGLAND JOURNAL OF MEDICINE, 1997, 336 (04) :243-250
[7]   A COMPUTER PROTOCOL TO PREDICT MYOCARDIAL-INFARCTION IN EMERGENCY DEPARTMENT PATIENTS WITH CHEST PAIN [J].
GOLDMAN, L ;
COOK, EF ;
BRAND, DA ;
LEE, TH ;
ROUAN, GW ;
WEISBERG, MC ;
ACAMPORA, D ;
STASIULEWICZ, C ;
WALSHON, J ;
TERRANOVA, G ;
GOTTLIEB, L ;
KOBERNICK, M ;
GOLDSTEINWAYNE, B ;
COPEN, D ;
DALEY, K ;
BRANDT, AA ;
JONES, D ;
MELLORS, J ;
JAKUBOWSKI, R .
NEW ENGLAND JOURNAL OF MEDICINE, 1988, 318 (13) :797-803
[8]  
Hilden J, 1996, STAT MED, V15, P969, DOI 10.1002/(SICI)1097-0258(19960530)15:10<969::AID-SIM211>3.0.CO
[9]  
2-9
[10]  
Hilden J, 2000, STAT MED, V19, P431, DOI 10.1002/(SICI)1097-0258(20000229)19:4<431::AID-SIM348>3.0.CO