Threshold Approach to Clinical Decision Making
1980
This classic paper provides a "tutorial" for students learning about diagnostic testing, probability revision, and how to calculate thresholds for testing, treatment, and no treatment. The authors describe how a physician's estimate of the probability that a patient has a particular disease is a principal factor in the determination of whether to withhold treatment, obtain more data by testing, or treat without subjecting the patient to the risks of further diagnostic tests.
Using the concepts of decision analysis, they derive expressions for two threshold probabilities involved in this choice: a “testing” threshold and a “test-treatment” threshold. Values are assigned to these thresholds from data on the reliability and potential risks of the diagnostic test and the benefits and risks of a specific treatment. Treatment is withheld if the probability of disease is smaller than the testing threshold, and treatment is given without further testing if the probability of disease is greater than the test-treatment threshold. The test is performed (with treatment depending on the test outcome) only if the probability of disease is between the two thresholds.
The method exposes important principles of decision making and helps students obtain qualitative insight using a quantitative approach to the efficient use of diagnostic tests.
Threshold Approach to Clinical Decision Making
Source:
Pauker SG, Kassirer JP. The Threshold Approach to Clinical Decision Making. NEJM 1980; 302: 1109-1117. https://doi.org/10.1056/NEJM198005153022003