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. 2013 Oct;22 Suppl 2(Suppl 2):ii11-ii20.
doi: 10.1136/bmjqs-2012-001616.

How much diagnostic safety can we afford, and how should we decide? A health economics perspective

David E Newman-Toker  1 , Kathryn M McDonald, David O Meltzer
Affiliations
Free PMC article

How much diagnostic safety can we afford, and how should we decide? A health economics perspective

David E Newman-Toker et al. BMJ Qual Saf. 2013 Oct.
Free PMC article
No abstract available

Keywords: Cost-effectiveness; Decision analysis; Decision making; Diagnostic errors.

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Figures

Figure 1
Figure 1
Tradeoffs versus improvements in diagnostic performance as illustrated by the ROC curve. (A) Performance tradeoffs (sliding along the ROC curve). In this scenario, clinicians alter their thresholds for seeking a particular diagnosis, but do not improve their overall diagnostic performance. Incentives, such as fear of malpractice litigation, drive physicians toward being ‘Nervous Nellies’, while incentives, such as productivity pressures, drive them towards being ‘Crazy Cowboys.’ (B) Performance improvements (moving the ROC curve). In this scenario, clinicians alter their diagnostic performance with regard to a particular diagnosis, rather than merely altering their threshold for decision making. Only incentives that focus on cost-effectiveness or ‘value’ (ie, combine ‘quality’ and ‘productivity’ measures) can drive clinicians to become ‘Deft Diagnosticians.’ Dx, diagnosis; ROC, receiver operating characteristic.
Figure 2
Figure 2
Societal value perspective on misdiagnosis reduction strategies.
Figure 3
Figure 3
Case example—Improving stroke diagnosis in acute dizziness and vertigo. We modelled cost-effectiveness of a novel eye-movement physiology-based approach, focusing on variable costs and effects related to diagnosis of strokes among ED patients with acute, continuous dizziness. We compared two blanket diagnostic strategies (MRI all, admit all) to current practice and our proposed strategy (bedside video-oculography (VOG)). We calculated incremental cost-effectiveness ratios (ICERs) from a societal perspective using dollars and quality-adjusted life years (QALYs). VOG could save many lives and is highly cost effective (∼US$7735 per QALY) in this subset of patients. Blue (non-dominated). Red (dominated: higher-cost, lower-quality alternatives).
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References

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