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Decision-analytic approaches to optimizing use of medical tests: methods and applications.

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Call No.	R723.5 .H47 2001
Author	Hersh, Adam
Title	Decision-analytic approaches to optimizing use of medical tests: methods and applications.
Date	2001
Abstract	This dissertation focuses on the use of decision analysis to study the optimal use of medical tests. The classic threshold model of clinical decision making provides methodological background and motivation for the dissertation. In this model, disease is dichotomized (D+ and D-), test results are dichotomized (T+ and T-) by a single threshold and it is assumed that two management actions are available, treat (A+) and no treat (A-). In Study 1, we extend the assumptions of the classic threshold model to include three management actions of increasing intensity (A-, A, A+) and three test result categories (T-, T, T+). The trichotomous test result structure is created by using two thresholds. Using a decision analytic model, we derive the pretest probability of disease (p(D)) thresholds bounding the testing region for the trichotomous test, within which performing the test has higher expected utility than performing A-, A* or A+. We discuss the conditions favoring a trichotomous test structure relative to a dichotomous structure and derive the p(D) thresholds to explicitly identify when the trichotomous structure has higher expected utility than the dichotomous structure. Finally, we derive expressions to locate the optimal operating points on the ROC curve for the two test thresholds. In Study 2, we expand the decision analytic model from Study 1 to compare a two-test strategy (T1/T2) to a single-test strategy (either T1 or T2). In the two-test strategy, the first test is trichotomized and T* results receive A*, which represents performing the second test. We examine two-test strategies in both prescreening and confirmatory test settings. In a prescreening strategy, T1/T2 is compared to using T2 only while in a confirmatory strategy, T1/T2 is compared to using T1 only. From the decision model, we derive a rule to identify when the two-test strategy has higher expected utility than the single-test strategy in terms of the test thresholds and the (dis)utility of receiving the test(s). In Study 3, we apply the methods developed in Studies 1 and 2 to clinical examples of screening for osteoporosis and screening for infection with Mycobacterium tuberculosis.
Description	1 online resource (xii, 130 leaves) : illustrations
Format	application/pdf
Advisor	Tosteson, Anna
Subject	Clinical medicine -- Decision making -- Mathematical models. ; Diagnosis Laboratory. ; Medical screening -- Mathematical models. ; Osteoporosis -- Diagnosis. ; Mycobacterial diseases -- Diagnosis.
College	Dartmouth Medical School -- Center for the Evaluative Clinical Sciences.
Issuing Body	Dartmouth Dissertations are made available through the Dartmouth Digital Library.
Degree	Thesis (Ph.D)--Dartmouth College.
Copyright	In Copyright. This material is protected by copyright and/or related rights. You are free to use this material in any way that is permitted by copyright law that applies to your use. For other uses, you need to obtain permission from the rights-holder(s). http://rightsstatements.org/page/InC/1.0/
DOI	https://doi.org/10.1349/ddlp.2755

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