Towards Evidence-Based Diagnosis

Lead Research Organisation: MRC Health Services Resrch Collaboration

Abstract

Diagnosis is an essential part of clinical practice. If a correct diagnosis is not made then patients may receive inaccurate information about their prognosis, may undergo inappropriate medical treatment, or the correct treatment may be withheld. It is therefore essential that diagnostic tests, which we have defined quite broadly to include tests (e.g. biochemical or imaging), clinical examination and history taking, are evaluated in the same way that medical treatments are evaluated. Currently, there has been a relatively small amount of research on the accuracy of diagnostic tests compared to the evidence available on the effectiveness of different treatments. Studies that have been done are often of poor quality and so the results that they produce may not be reliable, or may not be transferable to what happens in practice.||The aim of this research programme is to examine how we can best evaluate diagnostic tests, how we can make this information applicable to clinical practice and how the results of this research can be presented in a way that is easy for doctors and other health professionals to understand. We will also look at how we can bring together the results of different studies that have looked at the same test or the diagnosis of the same condition, taking into account both economic costs and patient values.|||

Technical Summary

Despite the crucial importance of an appropriate use of diagnostic and screening tests in clinical decision making, many tests, clinical findings and items from medical history have not been subjected to rigorous evaluation in studies following modern standards of clinical epidemiology. Sophisticated and expensive tests that are disseminated without suitable evaluations can subsequently be found to have marginal clinical value and economic benefit. Whereas considerable progress has been made to build a systematically assembled and critically appraised evidence base for the evaluation of efficacy and cost-effectiveness of therapeutic and preventive interventions, the diagnostic process is under-researched, the relevant literature is scattered and difficult to access, and the studies found are often of inadequate methodological quality or uncertain applicability. ||This programme aims to use both quantitative and qualitative methods to examine how the existing evidence base can be made more accessible and to investigate its methodological quality, applicability and the barriers to its optimal use in clinical practice. We are investigating how best to synthesize and present data to practitioners, and how to integrate the evidence from test evaluation studies with other sources of information, including economic data and patient values. ||The long-term aim is the development of interventions to improve diagnostic cost-effectiveness, based on the results of the research performed in this programme. Specific programmes are:||(1) To investigate barriers to optimal use by clinicians of the existing evidence base, using qualitative methods, including the role of cognitive biases, the role of different types of stressors, the experience of the health professional, and attitudes to the Bayesian framework.||(2) To develop designs for systematic reviews that optimise their usefulness for decision makers in different settings. In particular, to clarify the role of different study types in systematic reviews, to examine the place of statistical synthesis (meta-analysis) and to develop new statistical methods where appropriate, and to evaluate different measures of diagnostic accuracy for summarising results from test evaluation studies, with an emphasis on measures that have been identified as clinically useful.||(3) Modelling and optimising the process of diagnosis and comparing the process of diagnosis in the NHS with that in insurance-based health care systems.||

Publications

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Busby J (2013) Temporal growth and geographic variation in the use of laboratory tests by NHS general practices: using routine data to identify research priorities. in The British journal of general practice : the journal of the Royal College of General Practitioners

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Harbord RM (2007) A unification of models for meta-analysis of diagnostic accuracy studies. in Biostatistics (Oxford, England)

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Whiting P (2008) Evidence-based diagnosis. in Journal of health services research & policy

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Whiting P (2018) Accuracy of cystatin C for the detection of abnormal renal function in children undergoing chemotherapy for malignancy: a systematic review using individual patient data. in Supportive care in cancer : official journal of the Multinational Association of Supportive Care in Cancer

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Whiting P (2007) A review identifies and classifies reasons for ordering diagnostic tests. in Journal of clinical epidemiology

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Whiting PF (2008) Graphical presentation of diagnostic information. in BMC medical research methodology

 
Description Citation of unification model paper in systematic reviews.
Geographic Reach Multiple continents/international 
Policy Influence Type Citation in systematic reviews
 
Description Cochrane Diagnostic Test Accuracy (DTA) Review Handbook
Geographic Reach Multiple continents/international 
Policy Influence Type Influenced training of practitioners or researchers
 
Description NICE methdology workshop for diagnosis reviews
Geographic Reach National 
Policy Influence Type Participation in a national consultation
Impact Participated in discussion on proposed methods for the conduct of NICE appraisals to inform guidelines issued by NICE
 
Description MRC Health Services Research Collaboration
Amount £60,360 (GBP)
Organisation Medical Research Council (MRC) 
Sector Academic/University
Country United Kingdom
Start 08/2007 
End 07/2008
 
Description MRC Methodology Research Panel
Amount £703,000 (GBP)
Organisation Medical Research Council (MRC) 
Sector Academic/University
Country United Kingdom
Start 10/2009 
End 10/2012
 
Description NIHR HTA Programme Grant
Amount £181,512 (GBP)
Organisation National Institute for Health Research 
Department Health Technology Assessment Programme (HTA)
Sector Public
Country United Kingdom
Start 10/2007 
End 09/2008
 
Description NIHR HTA Programme Grant
Amount £3,255,160 (GBP)
Organisation National Institute for Health Research 
Department Health Technology Assessment Programme (HTA)
Sector Public
Country United Kingdom
Start 01/2010 
End 12/2012
 
Description Multiple Sclerosis Projects 
Organisation Carlo Besta Neurological Institute
Department Unit of Neuroepidemiology
Country Italy 
Sector Public 
PI Contribution We lead a project to conduct a systematic review on the accuracy of MRI for the diagnosis of MS.
Collaborator Contribution Professor Neil Scolding provided clinical advice to our projects related to the diagnosis of MSGraziella Filippini provided clinical advice for our review on the accuracy of MRI for the diagnosis of MS.
Impact PubMed ID: 16565096
 
Description Multiple Sclerosis Projects 
Organisation Frenchay Hospital
Country United Kingdom 
Sector Hospitals 
PI Contribution We lead a project to conduct a systematic review on the accuracy of MRI for the diagnosis of MS.
Collaborator Contribution Professor Neil Scolding provided clinical advice to our projects related to the diagnosis of MSGraziella Filippini provided clinical advice for our review on the accuracy of MRI for the diagnosis of MS.
Impact PubMed ID: 16565096
 
Description Swiss Group 
Organisation University of Bern
Department Institute of Social and Preventive Medicine
Country Switzerland 
Sector Academic/University 
PI Contribution We lead the project on graphical display of diagnostic information. We took on the project on empirical comparison of methods for meta-analysis of diagnostic accuracy data whilst a member of the Swiss Group was on maternity leave. Roger Harbord identified the mathematical link between two statistically rigorous models for the meta-analysis of diagnostic accuracy data. He took the lead on drafting this paper.
Collaborator Contribution Collaborated with Lucas Bachmann on the project on graphical display of diagnostic information. Lucas Bachmann, Matthias Egger and Aijing Shang developed the research question for the project on empirical comparison of methods for meta-analysis of diagnostic accuracy data. Matthias Egger contributed to the paper on unification of methods for meta-analysis of diagnostic accuracy.
Impact PubMed ID: 18405357, 19208372, 16698768
 
Description Tom Fahey 
Organisation University of Dundee
Department Tayside Centre for General Practice
Country United Kingdom 
Sector Academic/University 
PI Contribution We lead the proejct on test ordering and jointly organised a workshop on clinical prediction rules in primary care.
Collaborator Contribution Tom Fahey contributed to our paper on test ordering and we jointly organised a workshop on clinical prediction rules in primary care.
Impact PubMed ID: 17884591
 
Description York Group 
Organisation University of York
Department Centre for Reviews and Dissemination (CRD)
Country United Kingdom 
Sector Academic/University 
PI Contribution We lead the projects on graphical display of diagnostic information and literature searching. We collaborated on the grant proposal and review on colour vision testing for diabetic retinopathy. We also conducted the analysis.
Collaborator Contribution Marie Westwood and Julie Glanville worked with us on projects relating to literature searching and graphical display of diagnostic information. We also successfully applied for an NIHR HTA grant to conduct a systematic review on colour vision testing for diabetic retinopathy in collaboration with researchers from CRD.We continued to collaborate with Julie Glanville on literature searching projects after she moved from CRD to YHEC
Impact Publication, PubMed ID: 18405357, 18313560. NIHR HTA Grant Proposal on colour vision testing for diabetic retinopathy.
 
Description York Group 
Organisation University of York
Department York Health Economics Consortium (YHEC)
Country United Kingdom 
Sector Academic/University 
PI Contribution We lead the projects on graphical display of diagnostic information and literature searching. We collaborated on the grant proposal and review on colour vision testing for diabetic retinopathy. We also conducted the analysis.
Collaborator Contribution Marie Westwood and Julie Glanville worked with us on projects relating to literature searching and graphical display of diagnostic information. We also successfully applied for an NIHR HTA grant to conduct a systematic review on colour vision testing for diabetic retinopathy in collaboration with researchers from CRD.We continued to collaborate with Julie Glanville on literature searching projects after she moved from CRD to YHEC
Impact Publication, PubMed ID: 18405357, 18313560. NIHR HTA Grant Proposal on colour vision testing for diabetic retinopathy.
 
Description Frenchay Hospital Neurology Meeting - Bristol 
Form Of Engagement Activity A formal working group, expert panel or dialogue
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Professional Practitioners
Results and Impact Presentation of findings from systematic review on MRI for diagnosis of MS and general discussion of methods for evidence based diagnosis to consultant and registrars.

Impact not evaluated
Year(s) Of Engagement Activity 2006