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Developing the Topic and Structuring Systematic Reviews of Medical Tests: Utility of PICOTS, Analytic Frameworks, Decision Trees, and Other Frameworks

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Title: Developing the Topic and Structuring Systematic Reviews of Medical Tests: Utility of PICOTS, Analytic Frameworks, Decision Trees, and Other Frameworks


1
Developing the Topic and Structuring Systematic
Reviews of Medical Tests Utility of
PICOTS, Analytic Frameworks, Decision Trees, and
Other Frameworks
  • Prepared for
  • The Agency for Healthcare Research and Quality
    (AHRQ)
  • Training Modules for Medical Test Reviews Methods
    Guide
  • www.ahrq.gov

2
Overview of a Medical Test Review
Samson D, Schoelles KM. Developing the topic and
structuring systematic reviews of medical tests.
In Methods guide for medical test reviews.
Available at www.effectivehealthcare.ahrq.gov/medt
estsguide.cfm.
3
Learning Objectives
  • Describe a guideline for developing topics and
    structuring systematic reviews.
  • Understand the importance of interacting with
    stakeholders in formulating topics and their
    reviews.
  • Utilize PICOTS (population, intervention,
    comparator, outcomes, timing, and setting)
    typology, frameworks, and decision trees to
  • Minimize ambiguity.
  • Identify where resources should be focused.
  • Guide the presentation of results.
  • Recognize when it is sufficient to focus only on
    accuracy studies.

Samson D, Schoelles KM. Developing the topic and
structuring systematic reviews of medical tests.
In Methods guide for medical test reviews.
Available at www.effectivehealthcare.ahrq.gov/medt
estsguide.cfm.
4
Background
  • Topic development The process by which the
    foundation and structure of effective systematic
    reviews are created.
  • Through this process the reviewers will
  • Learn/clarify how a test might be of value in
    practice (e.g., specify the clinical context in
    which the test might be used)
  • Establish Key Questions to guide decisionmaking.
  • Structuring the review The process by which the
    most direct analytic strategy is identified to
    account for idiosyncrasies of the data.
  • These are complementary processes as the topic
    is developed/refined, the necessary structure of
    the review becomes more apparent.

Samson D, Schoelles KM. Developing the topic and
structuring systematic reviews of medical tests.
In Methods guide for medical test reviews.
Available at www.effectivehealthcare.ahrq.gov/medt
estsguide.cfm.
5
Challenges of Conducting Systematic Reviews of
Medical Tests
  • An ambiguous description of the claims regarding
    the test that does not identify
  • The target population
  • The specific role of the test in clinical
    decisionmaking
  • The indirect impact of medical tests requires
  • Linkage of medical tests, intermediate outcomes,
    and improved clinical outcomes
  • Identification of intermediate outcomes
  • Limitations of the scientific literature
  • Direct evidence for the effect of test strategies
    on health outcomes (e.g., randomized controlled
    trial results) is rare.
  • Intermediate outcomes (e.g., test accuracy) are
    often used instead.

Samson D, Schoelles KM. Developing the topic and
structuring systematic reviews of medical tests.
In Methods guide for medical test reviews.
Available at www.effectivehealthcare.ahrq.gov/medt
estsguide.cfm.
6
Principles Used To Address the Challenges of
Conducting a Systematic Review of Medical Tests
  1. Use the PICOTS (population, intervention,
    comparator, outcomes, timing, and setting)
    typology to engage stakeholders.
  2. Develop an analytic framework.
  3. Consider using decision trees.
  4. Sometimes it is sufficient to focus exclusively
    on accuracy studies.
  5. Other frameworks may be helpful.

Samson D, Schoelles KM. Developing the topic and
structuring systematic reviews of medical tests.
In Methods guide for medical test reviews.
Available at www.effectivehealthcare.ahrq.gov/medt
estsguide.cfm.
7
Principle 1 Use the PICOTS Typology To Engage
Stakeholders (1 of 4)
  • Often there is a wide variety of stakeholders
  • U.S. Food and Drug Administration
  • Government funding agencies
  • Technical and clinical experts
  • Patients
  • Health care providers
  • Payers
  • Policymakers
  • Manufacturers

PICOTS population, intervention, comparator,
outcomes, timing, and setting
Samson D, Schoelles KM. Developing the topic and
structuring systematic reviews of medical tests.
In Methods guide for medical test reviews.
Available at www.effectivehealthcare.ahrq.gov/medt
estsguide.cfm.
8
Principle 1 Use the PICOTS Typology To Engage
Stakeholders (2 of 4)
  • Hold a dialogue with stakeholders to understand
  • The objectives of the review
  • Generate Key Questions that address stakeholders
    needs.
  • Decisions the review is likely to affect.
  • The relationship of the tests to existing test
    strategies
  • Whether used as replacement, triage, or add-on.
  • Range of potential clinical utility.
  • Potential adverse consequences of testing.

PICOTS population, intervention, comparator,
outcomes, timing, and setting
Samson D, Schoelles KM. Developing the topic and
structuring systematic reviews of medical tests.
In Methods guide for medical test reviews.
Available at www.effectivehealthcare.ahrq.gov/medt
estsguide.cfm.
9
Principle 1 Use the PICOTS Typology To Engage
Stakeholders (3 of 4)
  • Discussions with stakeholders should focus on the
    PICOTS typology.
  • Refining topics is an iterative process.
  • The PICOTS elements may change as the clinical
    context become clearer.
  • Reviewers should consider a plan to manage these
    changes.

PICOTS population, intervention, comparator,
outcomes, timing, and setting
Samson D, Schoelles KM. Developing the topic and
structuring systematic reviews of medical tests.
In Methods guide for medical test reviews.
Available at www.effectivehealthcare.ahrq.gov/medt
estsguide.cfm.
10
Principle 1 Use the PICOTS Typology To Engage
Stakeholders (4 of 4)
  • Balance the need for information against the
    feasibility of completing the review.
  • Do the Key Questions reflect the needs of the
    stakeholders?
  • Is there enough time and resources to address all
    of these needs?
  • Are there existing systematic reviews or clinical
    guidelines that may be helpful
  • In describing current strategies for the tests
    being reviewed?
  • In revealing potential benefits and harms of the
    tests?

PICOTS population, intervention, comparator,
outcomes, timing, and setting
Samson D, Schoelles KM. Developing the topic and
structuring systematic reviews of medical tests.
In Methods guide for medical test reviews.
Available at www.effectivehealthcare.ahrq.gov/medt
estsguide.cfm.
11
Principle 2 Develop an Analytic Framework (1 of
2)
  • Analytic framework a graphical representation
    of patient care that
  • Starts from the point of intervention or testing.
  • Leads to all important health outcomes.
  • Reveals potential Key Questions along the way.
  • Is developed in consultation with stakeholders.
  • Strengthens the systematic review process by
  • Clarifying the link between testing, intermediate
    outcomes and clinical outcomes.
  • Clarifying Key Questions by illustrating
    important decisional dilemmas.

Samson D, Schoelles KM. Developing the topic and
structuring systematic reviews of medical tests.
In Methods guide for medical test reviews.
Available at www.effectivehealthcare.ahrq.gov/medt
estsguide.cfm.
12
Principle 2 Develop an Analytic Framework (2 of
2)
  • Prototypical Analytic Framework
  • Research Questions
  • Direct evidence that testing reduces
  • morbidity and/or mortality?
  • Test accuracy?
  • Impact of test on management?
  • Impact of management on health outcomes?
  • Impact of management on intermediate outcomes?
  • Impact of intermediate outcomes on health
    outcomes?
  • Adverse events, acceptability of test procedure?
  • Adverse events of subsequent treatment/ other
    tests?

Adapted from Harris RP, Helfand M, Woolf SH, et
al. Am J Prev Med. 2001 Apr20(3) Suppl21-35.
PMID 11306229.
13
Principle 3 Consider Using Decision Trees (1 of
2)
  • Analytic frameworks have limited ability to
  • Depict multiple alternative uses of a test.
  • Represent potential outcome consequences of
    altered clinical decisions due to test results.
  • Decision trees can be used in conjunction with
    analytic frameworks to
  • Illustrate the potential impact of test results
    on management decisions and outcomes.
  • Provide further clinical context of the topic.
  • Clarify Key Questions by
  • Identifying relevant indices of diagnostic
    accuracy and other statistics.
  • Revealing which range of possible pathways and
    outcomes logically flow from a test strategy.

Samson D, Schoelles KM. Developing the topic and
structuring systematic reviews of medical tests.
In Methods guide for medical test reviews.
Available at www.effectivehealthcare.ahrq.gov/medt
estsguide.cfm.
14
Principle 3 Consider Using Decision Trees (2 of
2)
  • A Sample Decision Tree for Breast Cancer Screening

Blue Cross Blue Shield Technology Evaluation
Center. Full-field digital mammography. TEC
Assessment. 2002 Jul(7).
15
Principle 4 Sometimes It Is Sufficient To Focus
Exclusively on Accuracy Studies (1 of 4)
  • When is it sufficient to develop Key Questions
    that link outcomes to diagnostic accuracy only?
  • Case 1
  • The new test is as sensitive and specific as the
    old test.
  • The new test also has advantages over the old
    test, such as
  • Fewer adverse effects.
  • Less invasive.
  • Easier to use.
  • Provides results more quickly.
  • Lower cost.
  • The downstream decisions and outcomes must be
    comparable between the two tests.

Samson D, Schoelles KM. Developing the topic and
structuring systematic reviews of medical tests.
In Methods guide for medical test reviews.
Available at www.effectivehealthcare.ahrq.gov/medt
estsguide.cfm.
16
Principle 4 Sometimes It Is Sufficient To Focus
Exclusively on Accuracy Studies (2 of 4)
  • When is it sufficient to develop Key Questions
    that link outcomes to diagnostic accuracy only?
  • Case 2
  • The new test has comparable sensitivity but
    greater specificity than the old test, which
    avoids further testing and unnecessary treatment.
  • The same cases must be detected by both tests.
  • Example Both tests detect early stage cancer,
    rather than the old test detecting early stage
    cancer while the new test detects metastatic
    cancer.
  • The treatment efficacy must be unaffected by
    which test is used.

Samson D, Schoelles KM. Developing the topic and
structuring systematic reviews of medical tests.
In Methods guide for medical test reviews.
Available at www.effectivehealthcare.ahrq.gov/medt
estsguide.cfm.
17
Principle 4 Sometimes It Is Sufficient To Focus
Exclusively on Accuracy Studies (3 of 4)
  • Questions to consider
  • Are extra cases detected by the new, more
    sensitive test similarly responsive to treatment?
  • Are trials available that include patients
    selected to undergo the new test?
  • Do trials assess whether the new test results
    predict response?
  • If available trials selected only patients
    assessed with the old test, do extra cases
    represent the same disease spectrum or subtypes
    as trial participants?
  • Are the cases detected with the tests
    subsequently confirmed by the same reference
    standard?
  • Does the new test change the definition or
    spectrum of disease (e.g., earlier stage)?
  • Is there heterogeneity of test accuracy and
    treatment effect (i.e., do accuracy and treatment
    effects vary sufficiently according to the levels
    of a patient characteristic to change the
    comparison of the old and new tests)?

Samson D, Schoelles KM. Developing the topic and
structuring systematic reviews of medical tests.
In Methods guide for medical test reviews.
Available at www.effectivehealthcare.ahrq.gov/medt
estsguide.cfm.
18
Principle 4 Sometimes It Is Sufficient To Focus
Exclusively on Accuracy Studies (4 of 4)
  • Diagnostic accuracy evidence alone may be
    sufficient to support conclusions about a new
    test if the following conditions are met
  • The answer to each of the questions below is
    yes.
  • Are extra cases detected by the new, more
    sensitive test similarly responsive to treatment?
  • Are trials available that selected patients to
    undergo the new test?
  • Do trials assess whether the new test results
    predict response?
  • If available trials selected only patients
    assessed with the old test, do extra cases
    represent the same disease spectrum or subtypes
    as trial participants?
  • Are the cases detected with the tests
    subsequently confirmed by the same reference
    standard?
  • The clinical utility of an older comparator test
    has been established.

Samson D, Schoelles KM. Developing the topic and
structuring systematic reviews of medical tests.
In Methods guide for medical test reviews.
Available at www.effectivehealthcare.ahrq.gov/medt
estsguide.cfm.
19
Principle 5 Other Frameworks May Be Helpful (1
of 3)
  • Use additional organizational frameworks to
  • Categorize the Key Questions.
  • Identify which types of studies will address
    specific questions in the review.
  • Review cluster studies together to improve
    readability.
  • Most organizational frameworks line up with the
    analytical framework and PICOTS elements.

PICOTS population, intervention, comparator,
outcomes, timing, and setting
Samson D, Schoelles KM. Developing the topic and
structuring systematic reviews of medical tests.
In Methods guide for medical test reviews.
Available at www.effectivehealthcare.ahrq.gov/medt
estsguide.cfm.
20
Principle 5 Other Frameworks May Be Helpful (2
of 3)
  • Other organizational frameworks generally
    classify medical test research into six different
    domains
  • Technical efficacy
  • Diagnostic accuracy
  • Diagnostic thinking efficacy
  • Therapeutic efficacy
  • Patient outcome
  • Societal aspects

Samson D, Schoelles KM. Developing the topic and
structuring systematic reviews of medical tests.
In Methods guide for medical test reviews.
Available at www.effectivehealthcare.ahrq.gov/medt
estsguide.cfm.
21
Principle 5 Other Frameworks May Be Helpful (3
of 3)
  • Six Research Domains Overlaid on the PICOTS
    Typology and an Analytic Framework

Samson D, Schoelles KM. Developing the topic and
structuring systematic reviews of medical tests.
In Methods guide for medical test reviews.
www.effectivehealthcare.ahrq.gov/medtestsguide.cfm
.
22
Cases Illustrating the Five Principles
  • The cases are three projects that followed this
    process of topic development
  • General topic
  • Initial ambiguous claim
  • Key concerns suggested by PICOTS, analytic
    frameworks, and decision trees
  • Refined claim
  • The cases represent one of three test classes
    replacement, add-on, and triage.

PICOTS population, intervention, comparator,
outcomes, timing, and setting
Samson D, Schoelles KM. Developing the topic and
structuring systematic reviews of medical tests.
In Methods guide for medical test reviews.
Available at www.effectivehealthcare.ahrq.gov/medt
estsguide.cfm.
23
Topic Refinement Process General Topics
  • Project 1 (replacement test) Full-field digital
    mammography to replace screen-film mammography in
    breast cancer screening
  • Project 2 (add-on test) Human epidermal growth
    factor receptor 2 (HER2) gene amplification assay
    as add-on to HER2 protein expression assay
  • Project 3 (triage test) Fluorodeoxyglucose
    positron emission tomography as triage for breast
    biopsy

Samson D, Schoelles KM. Developing the topic and
structuring systematic reviews of medical tests.
In Methods guide for medical test reviews.
Available at www.effectivehealthcare.ahrq.gov/medt
estsguide.cfm.
24
Sample Replacement Test Project FFDM Versus SFM
(1 of 4)
  • Initial ambiguous claim Full-field digital
    mammography (FFDM) may be a useful alternative to
    single-field mammography (SFM) in screening for
    breast cancer.
  • Key concerns suggested by the PICOTS typology, an
    analytic framework, and a decision tree
  • Key statistics sensitivity, diagnostic yield,
    and recall rate
  • Similar types of management decisions and
    outcomes for index and comparator test-and-treat
    strategies

PICOTS population, intervention, comparator,
outcomes, timing, and setting
Samson D, Schoelles KM. Developing the topic and
structuring systematic reviews of medical tests.
In Methods guide for medical test reviews.
Available at www.effectivehealthcare.ahrq.gov/medt
estsguide.cfm.
25
Sample Replacement Test Project FFDM Versus SFM
(2 of 4)
  • Refined claim
  • Interpretation, management decisions, and
    outcomes of the screening modalities of
    full-field digital mammography (FFDM) and
    single-field mammography (SFM) would be similar.
  • FFDM may have a similar recall rate and
    diagnostic yield at least as high as SFM.
  • FFDM images are more expensive but easier to
    manipulate and store.

Samson D, Schoelles KM. Developing the topic and
structuring systematic reviews of medical tests.
In Methods guide for medical test reviews.
Available at www.effectivehealthcare.ahrq.gov/medt
estsguide.cfm.
26
Sample Replacement Test Project FFDM Versus SFM
(3 of 4)
  • Decision tree developed to investigate downstream
    effects

Blue Cross Blue Shield Technology Evaluation
Center. Full-field digital mammography. TEC
Assessment 2002 Jul(7).
27
Sample Replacement Test Project FFDM Versus SFM
(4 of 4)
  • Using the decision tree yielded these results
  • The management decisions, accuracy, and
    downstream treatment outcomes for both full-field
    digital mammography (FFDM) and single-field
    mammography are similar.
  • The key test performance statistics identified
    were
  • Sensitivity
  • Diagnostic yield
  • Recall rate
  • FFDM was chosen as the preferred screening
    modality because of the ease with which it stores
    and manipulates images.

Samson D, Schoelles KM. Developing the topic and
structuring systematic reviews of medical tests.
In Methods guide for medical test reviews.
Available at www.effectivehealthcare.ahrq.gov/medt
estsguide.cfm.
28
Sample Add-on Test Project HER2 Gene
Amplification Assay (1 of 4)
  • Initial ambiguous claim
  • Amplification and protein expression assays of
    the human epidermal growth factor 2 (HER2) gene
    may complement each other as means of selecting
    patients for targeted therapy.
  • Key concerns suggested by the PICOTS typology, an
    analytic framework, and a decision tree
  • Key statistics The proportion of individuals
    with intermediate/ equivocal HER2 protein
    expression results who have HER2 gene
    amplification.
  • Key outcomes Are related to the effectiveness of
    HER2-targeted therapy in this subgroup.

PICOTS population, intervention, comparator,
outcomes, timing, and setting
Samson D, Schoelles KM. Developing the topic and
structuring systematic reviews of medical tests.
In Methods guide for medical test reviews.
Available at www.effectivehealthcare.ahrq.gov/medt
estsguide.cfm.
29
Sample Add-on Test Project HER2 Gene
Amplification Assay (2 of 4)
  • Refined claim
  • Patients with equivocal results for
    overexpression of human epidermal growth factor 2
    (HER2) protein but positive results for
    amplification of the HER2 gene may benefit from
    HER2-targeted therapy but otherwise would have
    been missed.

Samson D, Schoelles KM. Developing the topic and
structuring systematic reviews of medical tests.
In Methods guide for medical test reviews.
Available at www.effectivehealthcare.ahrq.gov/medt
estsguide.cfm.
30
Sample Add-on Test Project HER2 Gene
Amplification Assay (3 of 4)
  • Decision tree developed to investigate treatment
    outcomes

Seidenfeld J, Samson DJ, Rothenberg BM, et al.
Evid Rep Technol Assess Full Rep) 2008 Nov
(172)1-362. PMID 19408965.
31
Sample Add-on Test Project HER2 Gene
Amplification Assay (4 of 4)
  • Results from using the decision tree
  • Treatment outcomes are as important as test
    accuracy.
  • The key test performance statistic was
    identified
  • The proportion of individuals with equivocal
    protein expression results but with positive gene
    assay results.
  • A new Key Question was identified
  • Is HER2-targeted therapy (surgery and adjuvant
    chemotherapy with HER2-targeting agents)
    effective for patients with equivocal results on
    the protein assay but subsequently had positive
    amplified HER2 gene assay results?

Samson D, Schoelles KM. Developing the topic and
structuring systematic reviews of medical tests.
In Methods guide for medical test reviews.
Available at www.effectivehealthcare.ahrq.gov/medt
estsguide.cfm.
32
Sample Triage Test Project Positron Emission
Tomography (1 of 4)
  • Initial ambiguous claim
  • Positron emission tomography may play an
    adjunctive role to breast examination and
    mammography in detecting breast cancer and
    selecting patients for biopsy.
  • Key concerns suggested by the PICOTS typology, an
    analytic framework, and a decision tree
  • Key statistics Negative predictive value
  • Key outcomes Benefits of avoiding biopsy versus
    harms of delaying initiation of treatment for
    undetected tumors

PICOTS population, intervention, comparator,
outcomes, timing, and setting
Samson D, Schoelles KM. Developing the topic and
structuring systematic reviews of medical tests.
In Methods guide for medical test reviews.
Available at www.effectivehealthcare.ahrq.gov/medt
estsguide.cfm.
33
Sample Triage Test Project Positron Emission
Tomography (2 of 4)
  • Refined claim
  • If fluorodeoxyglucose positron emission
    tomography (FDG-PET) is performed before biopsy,
    women with negative FDG-PET results may avoid the
    adverse events of biopsy with potentially
    negligible risk of delayed treatment for an
    undetected tumor.

Samson D, Schoelles KM. Developing the topic and
structuring systematic reviews of medical tests.
In Methods guide for medical test reviews.
Available at www.effectivehealthcare.ahrq.gov/medt
estsguide.cfm.
34
Sample Triage Test Project Positron Emission
Tomography (3 of 4)
  • Decision tree developed to investigate several
    testing strategies

Samson DJ, Flamm CR, Pisano ED, et al. Acad
Radiol 2002 Jul9(7)773-83. PMID 12139091.
35
Sample Triage Test Project Positron Emission
Tomography (4 of 4)
  • Results from use of the decision tree
  • Key test performance statistic identified
    Negative predictive value of PET
  • Key difference in outcomes between testing
    strategies identified Harms of delaying
    treatment due to false negative PET vs. avoiding
    adverse effects of biopsy due to true negative
    PET
  • The review concluded that there is no significant
    benefit from using PET as triage

Samson D, Schoelles KM. Developing the topic and
structuring systematic reviews of medical tests.
In Methods guide for medical test reviews.
Available at www.effectivehealthcare.ahrq.gov/medt
estsguide.cfm.
36
Key Messages
  • Topic development/refinement should be -
  • Interactive and iterative.
  • Aimed at understanding and clarifying the test
    claim.
  • Performed with input from stakeholders.
  • PICOTS typology, analytic frameworks, decision
    trees, and other organizational frameworks are
    helpful in -
  • Minimizing ambiguity.
  • Identifying where resources should be focused.
  • Presenting results.
  • In specific instances, focusing only on accuracy
    studies (e.g. sensitivity and specificity) is
    sufficient.

PICOTS population, intervention, comparator,
outcomes, timing, and setting
Samson D, Schoelles KM. Developing the topic and
structuring systematic reviews of medical tests.
In Methods guide for medical test reviews.
Available at www.effectivehealthcare.ahrq.gov/medt
estsguide.cfm.
37
Practice Question 1 (1 of 2)
  • Understanding the clinical context of how a test
    will be used is important before starting a
    systematic review. All of the following are
    elements of clinical context except
  • Patient characteristics
  • Clinical setting
  • Sensitivity of the test
  • Management options

38
Practice Question 1 (2 of 2)
  • Explanation for Question 1
  • The correct answer is c. Test sensitivity is
    considered an intermediate outcome, not part of
    clinical context. Some of the elements of
    clinical context include patient characteristics,
    how the test will fit into existing pathways,
    technical details of the test, and management
    options.

39
Practice Question 2 (1 of 2)
  • What is the purpose of engaging stakeholders in
    topic development of a systematic review?
  • To understand the decisions the review is likely
    to affect.
  • To understand the range of potential clinical
    utility.
  • To understand potential adverse consequences of
    testing.
  • All of the above.

40
Practice Question 2 (2 of 2)
  • Explanation for Question 2
  • The correct answer is d. The stakeholders will be
    the users of the finished review. They should be
    engaged in discussions to understand the
    objectives of the review in practical terms in
    order to develop the review to best fit their
    needs.

41
Practice Question 3 (1 of 2)
  • Decision trees are used to
  • Outline the Key Questions for a systematic
    review.
  • Explain essential details of the test.
  • Show one set of possible outcomes that result
    from testing.
  • Represent the impact of test results on
    management decisions.

42
Practice Question 3 (2 of 2)
  • Explanation for Question 3
  • The correct answer is d. Decision trees are
    helpful for graphically showing the impact of
    test results on clinical decisions including the
    potential outcome consequences of altered
    decisions. Decision trees show the impact of test
    results on multiple management decisions and
    outcomes. A flow diagram would be a type of
    decision tree.

43
Practice Question 4 (1 of 2)
  • It is never sufficient to focus exclusively on
    accuracy studies when conducting a systematic
    review of a medical test.
  • True
  • False

44
Practice Question 4 (2 of 2)
  • Explanation for Question 4
  • The statement is false. There are certain
    settings where it is sufficient to focus
    exclusively on accuracy studies. For example,
    when a new test is as sensitive and as specific
    as the old test and the new test has advantages
    such as fewer adverse effects, then diagnostic
    accuracy may be sufficient to assess.

45
Authors
  • This presentation was prepared by Brooke
    Heidenfelder, Rachael Posey, Lorraine Sease, Remy
    Coeytaux, Gillian Sanders, and Alex Vaz, members
    of the Duke University Evidence-based Practice
    Center.
  • The module is based on Chapter 2, Developing the
    Topic and Structuring Systematic Reviews of
    Medical Tests Utility of PICOTS, Analytic
    Frameworks, Decision Trees,and Other Frameworks.
    In Methods Guide for Medical Test Reviews. AHRQ
    Publication No. 12-EC017. Rockville, MD Agency
    for Healthcare Research and Quality June 2012.
    www.effectivehealthcare.ahrq.gov/medtestsguide.cfm
    .

46
References (1 of 5)
  • Blakeley DD, Oddone EZ, Hasselblad V, et al.
    Noninvasive carotid artery testing. A
    meta-analytic review. Ann Intern Med. 1995 Mar
    1122(5)360-7. PMID 7847648. 
  • Blue Cross Blue Shield Technology Evaluation
    Center. Full-field digital mammography. TEC
    Assessment. 2002 Jul(7).
  • Feussner JR, Matchar DB. When and how to study
    the carotid arteries. Ann Intern Med. 1988 Nov
    15109(10)805-18. PMID 3056158. 
  • Harris RP, Helfand M, Woolf SH, et al. Current
    methods of the US Preventive Services Task Force
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