Use Of Inappropriate Tests Research Articles

Exploring How Sociocultural Factors Affect the Experience of Completing Neuropsychological Assessments Within Older Greek-Australians.

The field of cultural neuropsychology has grown exponentially over the last three decades. With a limited culturally informed evidence base to guide neuropsychological practice, the acceptability of existing paradigms has been called into question when applied to culturally diverse and educationally disadvantaged groups. This qualitative study aimed to explore the experiences of Greek Australian older adults who underwent a cognitive assessment to better understand potential barriers and facilitators to engagement and to improve neuropsychological assessment outcomes. Semi-structured interviews were developed to explore cultural attitudes and contextual factors relating to neuropsychological assessment. Interviews were conducted by Greek-speaking neuropsychologists using a sample of 10 healthy elderly Greek Australians following the completion of a comprehensive neuropsychological assessment. Data were analyzed using a phenomenological design within a critical realist framework. Analysis revealed the emergence of three broad themes: sociocultural factors, experiences within the broader medical system, and the assessment experience. Engagement with cognitive assessment was influenced by several factors, including rapport building, understanding of the assessment, and use of inappropriate tests. Furthermore, level and quality of education, sex differences, language barriers, acculturation, previous experiences of prejudice, anxiety, and a preference for Greek-speaking clinicians were additional factors reported to affect the client experience and validity of assessment outcomes. Neuropsychological assessment is, in part, affected by culturally reinforced attitudes. Failing to adjust the relationship between the clinician and client, test environment, style of communication, and the use of culturally inappropriate tests is likely to affect the validity of assessment outcomes.

Who Gets a Laboratory Test in Hospital, Why, and How Often? A Retrospective Observational Study of 4 Australian Hospitals

Laboratory providers are challenged with the need to deliver improvements in the efficiency and effectiveness of laboratory services. Initiatives have been set to reduce the inappropriate use of tests; however, empirical evidence about the rate and frequency of laboratory tests in hospitals has not been widely available. This study used data linkage techniques to investigate laboratory test use among Australian inpatients. A retrospective observational study was conducted across 3 metropolitan and 1 rural hospital, all serviced by a single laboratory provider. Data for all admitted inpatients between January 2008 and December 2013 were extracted and linked to determine the proportion of admissions with a laboratory test, number of tests per admission, and time to first test. This study included 521480 admissions. Of these, 83.7% had a pathology test. Newborns and neonates had the lowest percentage of admissions with tests (35.2%), whereas admissions for diseases and disorders of the hepatobiliary system and pancreas had the highest (97.5%). Patients had a median of 12 tests per admission. Patients 80-84 years of age had the highest rate of tests per admission (median, 19; interquartile range, 9-36). Forty-nine percent of patients' first tests occurred within 2 h of admission, increasing to 69.9% within 4 h. The vast majority of patients admitted to hospital received laboratory tests. Higher laboratory testing rates were observed with increasing age. These findings can be used to define and compare laboratory testing among inpatients and help identify sources of variation in laboratory testing.

Impacto del sobrediagnóstico y sobretratamiento en el paciente, el sistema sanitario y la sociedad

The medical activity displays a set of skills aimed at improving the health status of people. In this way, diagnoses are made, choices of tests and treatments are made, and decisions are made about what to do and what not to do that affect the lives of patients. In this article, we propose a reflection on overdiagnosis and overtreatment in relation to the factors that promote it and the impact they have on society, on the functioning of the health system and also directly on patients. Finally, we make some proposals on how to address this overuse considering that primary care is a privileged place to adapt and minimize the impact of the actions of the health system on the health of citizens and reduce the incidents of patient safety linked to the overdiagnosis and inappropriate use of tests and treatments that do not add value to the health of patients.

Overtesting and undertesting in primary care: a systematic review and meta-analysis

BackgroundHealth systems are currently subject to unprecedented financial strains. Inappropriate test use wastes finite health resources (overuse) and delays diagnoses and treatment (underuse). As most patient care is provided in...

A call to action: The controversy of and rationale for competency-based medical education

Although medical education has enjoyed many successes over the last century, there is a recognition that health care is too often unsafe and of poor quality. Errors in diagnosis and treatment, communication breakdowns, poor care coordination, inappropriate use of tests and procedures, and dysfunctional collaboration harm patients and families around the world. These issues reflect on our current model of medical education and raise the question: Are physicians being adequately prepared for twenty-first century practice? Multiple reports have concluded the answer is “no.” Concurrent with this concern is an increasing interest in competency-based medical education (CBME) as an approach to help reform medical education. The principles of CBME are grounded in providing better and safer care. As interest in CBME has increased, so have criticisms of the movement. This article summarizes and addresses objections and challenges related to CBME. These can provide valuable feedback to improve CBME implementation and avoid pitfalls. We strongly believe medical education reform should not be reduced to an “either/or” approach, but should blend theories and approaches to suit the needs and resources of the populations served. The incorporation of milestones and entrustable professional activities within existing competency frameworks speaks to the dynamic evolution of CBME, which should not be viewed as a fixed doctrine, but rather as a set of evolving concepts, principles, tools, and approaches that can enable important reforms in medical education that, in turn, enable the best outcomes for patients.

Current knowledge on the laboratory diagnosis of Clostridium difficile infection.

Clostridium difficile (C. difficile) is a spore-forming, toxin-producing, gram-positive anaerobic bacterium that is the principal etiologic agent of antibiotic-associated diarrhea. Infection with C. difficile (CDI) is characterized by diarrhea in clinical syndromes that vary from self-limited to mild or severe. Since its initial recognition as the causative agent of pseudomembranous colitis, C. difficile has spread around the world. CDI is one of the most common healthcare-associated infections and a significant cause of morbidity and mortality among older adult hospitalized patients. Due to extensive antibiotic usage, the number of CDIs has increased. Diagnosis of CDI is often difficult and has a substantial impact on the management of patients with the disease, mainly with regards to antibiotic management. The diagnosis of CDI is primarily based on the clinical signs and symptoms and is only confirmed by laboratory testing. Despite the high burden of CDI and the increasing interest in the disease, episodes of CDI are often misdiagnosed. The reasons for misdiagnosis are the lack of clinical suspicion or the use of inappropriate tests. The proper diagnosis of CDI reduces transmission, prevents inadequate or unnecessary treatments, and assures best antibiotic treatment. We review the options for the laboratory diagnosis of CDI within the settings of the most accepted guidelines for CDI diagnosis, treatment, and prevention of CDI.

Implementation of recommendations for the screening of hydroxychloroquine retinopathy: poor adherence of rheumatologists and ophthalmologists.

The American Academy of Ophthalmology published in 2011 revised recommendations regarding screening for hydroxychloroquine (HCQ) toxicity. We aimed to assess implementation of these recommendations by rheumatologists and ophthalmologists. A questionnaire regarding screening practices for HCQ toxicity was distributed among all members of the Israeli societies of Rheumatology and Ophthalmology. A total of 128 physicians responded to the questionnaire (rheumatologists: 60, ophthalmologists: 68). Only 5% of the rheumatologists and 15% of the ophthalmologists are aware of ophthalmologic assessments recommended for baseline and follow-up evaluation. When an abnormal test is detected, even if inappropriate for HCQ toxicity screening, 60% of the responders recommend cessation of therapy. Only 13% of the responders recommend first follow-up after five years for patients without risk factors; the remainder recommend more frequent testing. Ninety-six percent of the responders are not aware of all of the known risk factors for HCQ toxicity. Use of inappropriate tests to detect HCQ retinal toxicity may lead to unnecessary cessation of beneficial treatment with risk of disease flare, while lack of consideration of risk factors may put patients at risk for toxicity. These results emphasize the importance of implementing the recommendations to ensure safe and effective use of this drug.

Influence of educational, audit and feedback, system based, and incentive and penalty interventions to reduce laboratory test utilization: a systematic review.

Laboratory and radiographic tests are often ordered unnecessarily. This excess testing has financial costs and is a burden on patients. We performed a systematic review to determine the effectiveness interventions to reduce test utilization by physicians. The MEDLINE and EMBASE databases were searched for the years 1946 through to September 2013 for English articles that had themes of test utilization and cost containment or optimization. Bibliographies of included papers were scanned to identify other potentially relevant studies. Our search resulted in 3236 articles of which 109 met the inclusion criteria of having an intervention aimed at reducing test utilization with results that could be expressed as a percent reduction in test use relative to the comparator. Each intervention was categorized into one or more non-exclusive category of education, audit and feedback, system based, or incentive or penalty. A rating of study quality was also performed. The percent reductions in test use ranged from a 99.7% reduction to a 27.7% increase in test use. Each category of intervention was effective in reducing test utilization. Heterogeneity between interventions, poor study quality, and limited time horizons makes generalizations difficult and calls into question the validity of results. Very few studies measure any patient safety or quality of care outcomes affected by reduced test use. There are numerous studies that use low investment strategies to reduce test utilization with one time changes in the ordering system. These low investment strategies are the most promising for achievable and durable reductions in inappropriate test use.

Understanding validity issues surrounding test-based accountability measures in the US

Purpose– This AERI-NEPC eBrief, the fourth in a series titled “Understanding validity issues around the world”, looks closely at issues surrounding the validity of test-based actions in educational accountability and school improvement contexts. The specific discussions here focus testing issues in the US. However, the general principles underlying appropriate and inappropriate test use in school reform and high stakes public accountability settings are applicable in both domestic and international settings. This paper aims to present the issues.Design/methodology/approach– This policy brief is based on a synthesis of conference proceedings and review of selected pieces of extant literature. It begins by summarizing perspectives of an invited expert panel on the topic. To that synthesis, the authors add their own analysis of key issues. They conclude by offering recommendations for test developers and test users.Findings– The authors conclude that recurring validity issues arise with tests used in school reform and public accountability contexts, because the external tests tend to be employed as policy instruments to drive reforms in schools, with unrealistic timelines and inadequate resources. To reconcile the validity issues with respect to educational assessment and forge a coherent understanding of validity among multiple public users with different agendas, the authors offer several recommendations, such as: adopt an integrated approach to develop content and standards of proficiency that represent a range of cognitive processes; support studies to examine validity of assessments and the effects of decisions taken with assessment data before results are fed into high stakes accountability-related actions that affect teachers, leaders or schools; align standards, curricula, instruction, assessment, and professional development efforts in schools to maximize success; increase capacity-building efforts to help teachers, administrators, policy makers, and other groups of test users learn more about assessments, particularly, about appropriate interpretation and use of assessment data and reports.Originality/value– Baker points out that in response to growing demands of reformers and policy-makers for more frequent and rigorous testing programs in US public education, results from a single test tend to get used to meet a variety of public education needs today (e.g. school accountability, school improvement, teacher evaluation, and measurement of student performance). While this may simply be a way to make things more cost-efficient and reduce the extent of student testing in schools, a consequence is inappropriate test use that threatens validity in practice settings. This policy brief confronts this recurring validity challenge and offers recommendations to address the issues.

Direct to Consumer Genetic Testing

Within the health care system, genetic tests for monogenic disorders are ordered by a health professional, and the results are interpreted and conveyed to the patient by that person. With the availability of direct-to-consumer genetic testing (DTCGT), individuals can buy genetic testing kits and obtain results without the assistance of a professional. One factor mentioned in support of DTCGT is that individuals can make an autonomous choice to have a test that may affect their health. However, these persons must be aware of the value, risks, and benefits of a particular test. Often, information provided with a DTCGT is difficult to understand, or critical data are unavailable. Professional societies/organizations either want to prohibit such tests or accept them with specific controls and conditions. This review was undertaken to assess the current position statements and recommendations of several professional organizations on the use of DTCGT. Relevant electronic databases and Web pages were searched using the terms “direct to consumer” and “genetic test.” The review included documents describing a position statement, policy, guideline, or recommendations for use of DTCGT related directly to health in any country and produced by a professional organization or other relevant body. From 305 items for review, 300 were excluded; other items were found through searches of Google and health professional and bioethics Web sites, resulting in 14 documents available for review. Six documents were produced by professional colleges or societies in the United States, 2 by European societies, and 6 by public bodies in Europe. Potential benefits of DTCGT described included the right of individuals to have access to their own genetic information (personal autonomy), but this was weighed against the use of inappropriate tests and threats to an individual’s well-being. Three groups thought the benefits included availability of additional information, an empowering effect, and improved access to genetic testing. Other benefits were avoidance of unneeded clinical investigations or screening and initiation of early intervention in the context of equitable access to tests. The most common potential harms were risks to the individual’s privacy/confidentiality, consumers’ failure to recognize that results might have an effect on their future insurance or employment status, an overstatement of the actual predictive power of the results obtained through the tests, and questionable value of the results. Most organizations expressed concerns that users might be inappropriately reassured by inaccurate test results or by misinterpreting results. Four organizations indicated that tests should not be available for diagnostic or predictive purposes, tests should be discouraged, or only genetic tests meeting stringent criteria should be available. Recommendations were made that trained and qualified health professionals must provide accurate information and counseling before and after the testing. These aspects could place additional burdens on health care systems when consumers require information and support after performing the tests. Education of health professionals is necessary to support consumers undergoing DTCGT. These results suggest that professional associations and public organizations are more concerned about potential harms for patients using DTCGT than they are supportive of possible benefits. Although these professional organizations voiced concerns about the use of DTCGT, each has its own approach and recommendations. Because marketing of DTCGT is now international, a more coherent and systematic approach is required to ensure that health professionals are well informed about the potential advantages and risks to their patients. This approach would require a standard for information provided to professionals and consumers, identification of tests that should not be available without access to genetic counseling, and sufficient education for health professionals regarding the tests.

Direct to Consumer Genetic Testing

Within the health care system, genetic tests for monogenic disorders are ordered by a health professional, and the results are interpreted and conveyed to the patient by that person. With the availability of direct-to-consumer genetic testing (DTCGT), individuals can buy genetic testing kits and obtain results without the assistance of a professional. One factor mentioned in support of DTCGT is that individuals can make an autonomous choice to have a test that may affect their health. However, these persons must be aware of the value, risks, and benefits of a particular test. Often, information provided with a DTCGT is difficult to understand, or critical data are unavailable. Professional societies/organizations either want to prohibit such tests or accept them with specific controls and conditions. This review was undertaken to assess the current position statements and recommendations of several professional organizations on the use of DTCGT. Relevant electronic databases and Web pages were searched using the terms “direct to consumer” and “genetic test.” The review included documents describing a position statement, policy, guideline, or recommendations for use of DTCGT related directly to health in any country and produced by a professional organization or other relevant body. From 305 items for review, 300 were excluded; other items were found through searches of Google and health professional and bioethics Web sites, resulting in 14 documents available for review. Six documents were produced by professional colleges or societies in the United States, 2 by European societies, and 6 by public bodies in Europe. Potential benefits of DTCGT described included the right of individuals to have access to their own genetic information (personal autonomy), but this was weighed against the use of inappropriate tests and threats to an individual’s well-being. Three groups thought the benefits included availability of additional information, an empowering effect, and improved access to genetic testing. Other benefits were avoidance of unneeded clinical investigations or screening and initiation of early intervention in the context of equitable access to tests. The most common potential harms were risks to the individual’s privacy/confidentiality, consumers’ failure to recognize that results might have an effect on their future insurance or employment status, an overstatement of the actual predictive power of the results obtained through the tests, and questionable value of the results. Most organizations expressed concerns that users might be inappropriately reassured by inaccurate test results or by misinterpreting results. Four organizations indicated that tests should not be available for diagnostic or predictive purposes, tests should be discouraged, or only genetic tests meeting stringent criteria should be available. Recommendations were made that trained and qualified health professionals must provide accurate information and counseling before and after the testing. These aspects could place additional burdens on health care systems when consumers require information and support after performing the tests. Education of health professionals is necessary to support consumers undergoing DTCGT. These results suggest that professional associations and public organizations are more concerned about potential harms for patients using DTCGT than they are supportive of possible benefits. Although these professional organizations voiced concerns about the use of DTCGT, each has its own approach and recommendations. Because marketing of DTCGT is now international, a more coherent and systematic approach is required to ensure that health professionals are well informed about the potential advantages and risks to their patients. This approach would require a standard for information provided to professionals and consumers, identification of tests that should not be available without access to genetic counseling, and sufficient education for health professionals regarding the tests.

Risk factors for delayed presentation and referral of symptomatic cancer: evidence for common cancers

Background:It has been suggested that the known poorer survival from cancer in the United Kingdom, compared with other European countries, can be attributed to more advanced cancer stage at presentation. There is, therefore, a need to understand the diagnostic process, and to ascertain the risk factors for increased time to presentation.Methods:We report the results from two worldwide systematic reviews of the literature on patient-mediated and practitioner-mediated delays, identifying the factors that may influence these.Results:Across cancer sites, non-recognition of symptom seriousness is the main patient-mediated factor resulting in increased time to presentation. There is strong evidence of an association between older age and patient delay for breast cancer, between lower socio-economic status and delay for upper gastrointestinal and urological cancers and between lower education level and delay for breast and colorectal cancers. Fear of cancer is a contributor to delayed presentation, while sanctioning of help seeking by others can be a powerful mediator of reduced time to presentation. For practitioner delay, ‘misdiagnosis’ occurring either through treating patients symptomatically or relating symptoms to a health problem other than cancer, was an important theme across cancer sites. For some cancers, this could also be linked to inadequate patient examination, use of inappropriate tests or failing to follow-up negative or inconclusive test results.Conclusion:Having sought help for potential cancer symptoms, it is therefore important that practitioners recognise these symptoms, and examine, investigate and refer appropriately.

Potentially Inappropriate Repeat Laboratory Testing in Inpatients

Information technology provides data that are useful for assessing potentially unnecessary repeat laboratory testing (1)(2). Rather than using these data to directly measure the appropriateness of laboratory testing, we identified an outcome that we believe is indicative of inappropriate testing the majority of times. This useful surrogate measure of potentially inappropriate test use within and between departments and institutions can help to standardize discussion of this problem. We extended the approach of Weydert et al. (3), who calculated an index of test overuse by counting inpatients with serum sodium results within reference intervals on ≥4 consecutive days over a 1-month period and presented the monthly volume of tests ordered on these patients as a proportion of the total sodium testing workload. At Tan Tock Seng Hospital, a 1200-bed acute-care hospital in central Singapore, we examined repeat testing on inpatients for the top 14 analytes by volume and repeat testing rates in the different clinical departments over a 1-year period. All 2002 records for the …

Do‐it‐yourself diagnosis

Sandra Thomas is a trailblazer in the brave new world of genetic testing. Less than 5% of Americans have undergone a single genetic test, but the 56‐year‐old Florida woman has taken a dozen tests of the sort now available over the internet. Thomas is unmarried and has no children, but wanted to know if she has the mutation for haemochromatosis, the disease that killed her mother. Tests for two genes uncovered that she is a carrier of the potentially deadly but treatable iron‐overload disease. The tests also gave Thomas a passion for genetic testing in general. She found she has genes that put her at an above‐average risk for periodontal disease, which prompted her to improve her oral hygiene. The results of further tests, which she declined to name, have put her mind at ease about developing other serious conditions.(Fig 1) Figure 1. Some might consider Thomas a genetic‐testing hypochondriac, but she maintained, “I'm just ahead of my time.” Annette Taylor, a molecular geneticist and founder of Kimball Genetics (Denver, CO, USA), which runs genetics tests for major reference labs and now offers direct‐to‐consumer (DTC) testing, said, “Sandra is passionate about gathering information.” Testing for genetic disorders is becoming almost as easy as taking a home pregnancy test. People can use their credit card to order a kit on the internet, use a brush to remove a few cheek cells, return the kit and receive a report via e‐mail, often without involving their personal physicians. DTC tests cost from a few hundred to a few thousand US dollars, and are available for more than 800 conditions including breast and ovarian cancer, cystic fibrosis, coeliac disease, blood‐clotting disorders, dyslipidaemia, fragile X syndrome, Tay–Sachs disease and narcolepsy. > Testing for genetic disorders is becoming almost as easy as taking a home pregnancy test …

Diagnostic accuracy of flow rate testing in urology

To highlight the importance of methodological standards in diagnostic testing in urology, by reviewing the extent of compliance with these standards in reports of published evaluations. Sixteen papers evaluating the diagnostic accuracy of urinary flow-rate testing were independently assessed by two reviewers for compliance with the following methodological standards: specification of study population, analysis of pertinent subgroups, avoidance of evaluation (verification) bias, avoidance of review bias, reporting of precision of estimates of test accuracy, indeterminate test results, and test reproducibility. Compliance with each standard was expressed as a percentage with a 95% confidence interval. Compliance ranged from just 12.5 (1.5-38)% for reporting of test reproducibility to 87.5 (62-98)% for specification of the study population. Only nine of the 16 evaluations complied with four or more of the methodological standards; one paper did not comply with any. This evaluation of urological flow-rate testing show poor compliance with accepted methodological standards. The study design, reporting and evaluation of new diagnostic tests can be improved by adhering to these standards. Policy-makers, purchasers and providers would be less likely to adopt new diagnostic tests inappropriately if they were to appraise published evaluations against the standards. A reduction in the inappropriate use of tests would in turn lead to more cost-effective use of healthcare resources.

UK Takeovers and Acquiring Company Wealth Changes: The Impact of Survivorship and Other Potential Selection Biases on Post-Outcome Performance

A number of studies of takeover activity, both in the UK and elsewhere, have documented a pattern of long-run negative post-bid returns to shareholders of acquiring companies. One possible interpretation of the phenomena is that it represents a delayed market reaction to overpriced takeovers. An alternative explanation is that the phenomena is illusory and caused by methodological errors in the identification of long-run returns. These errors may arise through choice of inappropriate control models or through the introduction of some element of bias into the chosen sample, including the use of inappropriate tests of statistical significance. Potential sources of bias include survivorship and prior performance bias and the aggregation and testing of non-normal returns' distributions. In the current paper we demonstrate that the pattern of long-run negative returns to acquirers in UK acquisitions over the period 1977-1990 is not a function of survivorship bias. Nor do benchmark controls using both portfolios and matched pairs, with matching on book-to-market and size, provide results inconsistent with long-run negative wealth effects to shareholders of acquiring firms. However the application of test statistics that reflect the non-normal properties of distributions of long-run returns do reduce the significance of results based on parametric statistics. Our results also confirm that a number of characteristics of the acquiring firm can explain some of the cross-section distribution of wealth changes. In particular cash-financed acquisitions consistently outperform acquirers who rely on a method of financing based on equity. Cash-financed acquirers do not experience significant wealth changes when measured over a five-year post-acquisition period. We are unable to conclude that the negative wealth effects experienced by equity-financed acquirers is associated with long-run returns reversal, as tests that use benchmarks of companies matched on the basis of prior performance do not materially alter the pattern of negative long-run wealth losses. Large acquirers also suffer less-negative wealth effects than their smaller counterparts. In addition we also find that regular acquirers suffer no significant wealth losses, irrespective of the control model adopted, and consistently outperform single acquirers. This last finding does suggest that management do at least tend to learn from previous experience. In multiple regression tests, coefficients representing method of financing and experience of acquirers are the only variables that are significant. We find no evidence on any additional 'glamour versus value' effect after controlling for book-to-market and size.

Clinical utility of an international thyroid database

Assessment of thyroid function is prone to errors from several sources. Confusion is most often due to inappropriate use of tests, especially in patients with acute non-thyroid illness. With these problems in mind we have designed an international prospective thyroid database in three countries, which registers clinical and laboratory data on new patients with suspected thyroid disease. An additional aim was to assess the use of a computerised decision support tool to interpret thyroid data. The database permits rapid access to temporal trends in thyroid tests, which is useful in monitoring therapy and in follow up for hyperthyroidism. Marked contrasts in local clinical practices have highlighted the challenge in providing a valid decision tool to serve all clinical needs. Experience with multi-centre databases such as this hold promise in the drive to coordinate the disciplines of laboratory analysis and clinical decision making.

Statistical tests in medical research.

Various propositions have been made to improve the statistical quality of medical journals: using statistical referees, promoting better collaboration between statisticians and researchers, and teaching of basic statistics to clinicians. The most frequent errors found in medical articles are misinterpretation of p-values or non-significant results and confusion between statistical and clinical significance, inappropriate use of tests requiring precise assumptions, inappropriate or not controlled multiple testing and particularly testing of post hoc hypotheses, and overemphasis on p-values. Many errors arising from the misinterpretation of results of statistical hypothesis tests, the basic principles of this methodology are emphasized, and the usual fallacies found in the medical literature are reviewed.

Common pitfalls in the evaluation of developmental screening tests

Wilson has written that screening puts a responsibility on the physician to provide some benefit to the person being screened. He made the distinction between the physician who is confronted by a patient with a problem that the physician may attempt to cure with unproved means, on one hand, and persons who mount community screening programs with unproved procedures on the other. He considers the former to be ethical and the latter unethical. Similarly, we consider the failure to avoid pitfalls--such as improper screening test administration, failure to use reliable outcome criteria, making inappropriate (although well-intentioned) predictions, and making inappropriate generalizations or drawing inappropriate conclusions--to be unethical. The pitfalls jeopardize the achievement of the desired outcome by screening programs. They also lead to inappropriate conclusions and possibly, therefore, to the use of inappropriate tests. If the scientific community does not take steps to avoid such pitfalls in developmental screening, it invites those who make health care decisions to eliminate such screening or to mandate procedures which may not be scientifically sound. Neither of these alternatives is acceptable. The only alternative, first, is to ensure that one avoids common pitfalls when screening in one's own practice and, second, to be on guard against developmental screening studies and reports that fail to avoid these errors.

Limited usefulness of the proportion of tests with normal results in review of diagnostic services utilization.

We tested the hypothesis that the proportion of normal results in tests ordered by a physician correlates directly with the proportion of tests that are disapproved by a utilization review audit for inappropriate test use. Auditors reviewed 3497 charts for 13 067 repeated determinations of 10 diagnostic tests ordered by 81 medical residents to determine if test use had been appropriate, according to explicit criteria. By the Pearson product-moment correlation coefficient, there was a significant (p less than 0.001) correlation between the proportion of normal results in tests ordered by residents and the residents' audit-disapproval rates, a previously undocumented relationship. Although statistically significant, the correlation coefficient of 0.25 means that the proportion of normal tests results predicted only 6% of the variance in the audit-disapproval rates. This relationship is not strong enough to use the proportion of normal results as a measure of a physician's inappropriate test use, except to select physicians for utilization review.