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• W2005995711 abstract "Although clinical thinking is an invisible process, it is the only way to give visible shape to the data gathered. In this issue of CHEST (see page 1264), Colice and colleagues remind us that appropriate application of a predefined set of clinical criteria (history, physical examination, and standard hematologic and chemistry profiles) before cranial CT in patients with lung cancer has a very high negative predictive value (.97 or greater).1Hooper RG Tenholder MF Underwood GH et al.Computed tomographic scanning of the brain in initial staging of bronchogenic carcinoma.Chest. 1984; 85: 774-776Crossref PubMed Scopus (61) Google Scholar Just as looking through a kaleidoscope from the narrow end gives the best images, studies designed to approach a testing process like cranial CT with the initial focus on the patient give us the best estimate of diagnostic adequacy or sufficiency. The authors have shown that the pursuit of diagnostic certainty to the point where the rare exception (unsuspected brain metastasis) is the operational paradigm, is not beneficial either from a risk or cost benefit standpoint. In order to ascribe benefit, many studies of imaging modalities like cranial CT have analyzed their results looking back from the testing procedure toward the patient. This attempt is similar to looking through the wide end of a kaleidoscope. There is no clear image produced. Emphasis is often given only to presence or absence of CNS symptoms. Nonorgan-specific signs and symptoms suggestive of metastases are frequently not described in these studies. The performance status for the patient (ie, the Karnofsky score) is seldom included. Can the patient actually tolerate any treatment for the intracranial finding? The costs engendered by investigation of false-positive results are rarely mentioned. This approach overemphasizes the value of the technological test for complete diagnosis even when the clinical circumstances and treatment options are not actually complex. Widespread use of economic analysis as part of the development of pharmaceutical, biotechnologic, and medical devices is relatively new.2Task Force on Principles for Economic Analysis of Health Care.Economic analysis of health care technology: a report on principles. Ann Intern Med. 1995; 122: 61-70Google Scholar The indepth peer review of articles on economic analysis requires special expertise. The task force on principles for economic analysis of health-care technology has just published guidelines to consider when evaluating the merit of these publications.2Task Force on Principles for Economic Analysis of Health Care.Economic analysis of health care technology: a report on principles. Ann Intern Med. 1995; 122: 61-70Google Scholar Cost effectiveness analysis incorporates both cost and effect. It measures the net cost of providing a service (expenditures minus savings) as well as the outcomes obtained.3Eisenberg JM Clinical economics: a guide to the economic analysis of clinical practices.JAMA. 1989; 262: 2879-2886Crossref PubMed Scopus (642) Google Scholar Almost all clinicians would agree that, at some point, the extra money spent for tiny improvements in clinical outcomes is not worthwhile and represents inappropriate practice.3Eisenberg JM Clinical economics: a guide to the economic analysis of clinical practices.JAMA. 1989; 262: 2879-2886Crossref PubMed Scopus (642) Google Scholar The study by Colice and colleagues in this issue compared two strategies in patients with lung cancer—CT first and no CT (CT-deferred). The authors have carefully described how important the influence of disease prevalence and prior probability should be in the decision to obtain cranial CT. They also provide appropriate emphasis on test sequencing. It is essential to ask if the cranial CT scan can make actual measurable difference in staging or treatment. It is only through this process that we can assess consequences of false-positive and false-negative results and arrive at a beneficial concept of a testing threshold. Dr. Ubel4Ubel PA Doctor talk: technology and modern conversation.Am J Med. 1995; 98: 587-588Abstract Full Text PDF PubMed Scopus (3) Google Scholar has expressed a fear that medical technology allows physicians to act as if we no longer need to talk to patients or each other. If we are going to convince the “next generation” of physicians that it remains essential to talk to patients and ascertain their physical findings,4Ubel PA Doctor talk: technology and modern conversation.Am J Med. 1995; 98: 587-588Abstract Full Text PDF PubMed Scopus (3) Google Scholar the principles of economic analysis must be incorporated in our medical teaching rounds to clarify rather than obscure the proper application of technology. The time-honored values of the history, physical examination, logical medical reasoning, and proper test sequencing will not be diminished by cost analysis, but rather the brilliance of the image at the other end of the kaleidoscope will be enhanced. The article by Colice and colleagues is a definitive step in the right direction." @default.
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• W2005995711 title "Clinical Economics Through the Kaleidoscope" @default.
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