Reassurance After Diagnostic Testing With a Low Pretest Probability of Serious Disease

Abstract

Importance: Diagnostic tests are often ordered by physicians in patients with a low pretest probability of disease to rule out conditions and reassure the patient.Objective: To study the effect of diagnostic tests on worry about illness, anxiety, symptom persistence, and subsequent use of health care resources in patients with a low pretest probability of serious illness.Evidence Acquisition: Systematic review and metaanalysis. We searched MEDLINE, the Cochrane Central Register of Controlled Trials, EMBASE, PsychINFO, CINAHL, and ProQuest Dissertations electronic databases through December 31, 2011, for eligible randomized controlled trials. We independently identified studies for inclusion and extracted the data. Disagreements were resolved by discussion. We performed metaanalysis if heterogeneity was low or moderate (I 2 Ͻ50%).Results: Fourteen randomized controlled trials that included 3828 patients met the inclusion criteria and were analyzed with outcomes categorized as short term (Յ3 months) or long term (Ͼ3 months). Three trials showed no overall effect of diagnostic tests on illness worry (odds ratio, 0.87 [95% CI, 0.55-1.39]), and 2 showed no effect on nonspecific anxiety (standardized mean difference, 0.06 [Ϫ0.16 to 0.28]). Ten trials showed no overall long-term effect on symptom persistence (odds ratio, 0.99 [95% CI, 0.85-1.15]). Eleven trials measured subsequent primary care visits. We observed a high level of heterogeneity among trials (I 2 =80%). Meta-analysis after exclusion of outliers suggested a small reduction in visits after investigation (odds ratio, 0.77 [95% CI, 0.62-0.96]).Conclusions and Relevance: Diagnostic tests for symptoms with a low risk of serious illness do little to reassure patients, decrease their anxiety, or resolve their symptoms, although the tests may reduce further primary care visits. Further research is needed to maximize reassurance from medically necessary tests and to develop safe strategies for managing patients without testing when an abnormal result is unlikely.

Watchful Waiting Strategy May Reduce Low-Value Diagnostic Testing

“…While specific aspects of physician-patient communication may reduce patient anxiety, test ordering does not seem to affect patient satisfaction, and diagnostic testing for patients at low risk of serious disease does little to reassure patients or resolve symptoms. 10 Our findings suggest that a watchful waiting approach might also be an effective means of reducing low-value diagnostic testing in US primary care settings.…”

“…10 Further, patients whose test requests are denied are less satisfied with their visits, 7,11 a matter of increasing concern to PCPs, who often receive incentives based on patient experience scores. There is a need to uncover strategies PCPs can use to address patient requests for low-value testing while maintaining patient and provider satisfaction.…”

Relationship of Opioid Prescriptions to Physical Therapy Referral and Participation for Medicaid Patients with New-Onset Low Back Pain

“…31,32 However, practitioners report using imaging as a way to provide reassurance and enhance the provider-patient relationship. 33 This assumption has not been supported 34 , although patients report increased satisfaction when they receive imaging. 35 Having this expectation met may increase compliance with provider recommendations such as PT.…”

Viewpoint: Doing nothing

“…Yet recent systematic reviews have shown that normal tests make virtually no difference to patient anxiety. 6 How often when we purport to be 'reassuring' our patients are we actually projecting our own anxiety onto them? In our qualitative study of inflammatory marker testing 4 a GP explained the problem with this:…”