Defining the clinical pathway in cochrane diagnostic test accuracy reviews

Abstract

Background: The value of a medical test depends on the context in which it might be used. Ideally, questions, results and conclusions of a diagnostic test accuracy (DTA) systematic review should be presented in light of this context. There is increasing acceptance of the value for knowing the impact a test can have on downstream consequences such as costs, implications for further testing and treatment options however there is currently no explicit guidance on how to address this. Authors of a Cochrane diagnostic review have recently been asked to include the clinical pathway in which a test maybe used. We aimed to evaluate how authors were developing their clinical pathways in the light of this.

Methods: We searched the Cochrane Database of Systematic Reviews for all published DTA reviews. We included only those reviews that included a clinical pathway. We developed a checklist, based on the guidance in the Cochrane Handbook for DTA review authors. To this, we added a number of additional descriptors. We checked if the included pathways fulfilled these descriptors as defined by our checklist.

Results: We found 47 reviews, of which 33 (73 %) contained aspects pertaining to a clinical pathway. The 33 reviews addressed the clinical pathway differently, both in content and format. Of these, 21 provided a textual description and 12 include visual and textual descriptions. There was considerable variation in how comprehensively review authors adhered to our checklist. Eighteen reviews (51 %) linked the index test results to downstream clinical management actions and patient consequences, but only eight went on to differentially report on the consequences for false negative results and nine on the consequences for false positive results.

Conclusion: There is substantial variation in the clinical pathway descriptions in Cochrane systematic reviews of test accuracy. Most reviews do not link misclassifications (i.e. false negatives and false positive) to downstream patient consequences. Review authors could benefit from more explicit guidance on how to create such pathways, which in turn can help guide them in their evidence selection and appraisal of the evidence in the context of downstream consequences of testing.

Keywords: Clinical pathways; Cochrane systematic reviews; Diagnostic tests; Guidelines; Medical tests; Test accuracy studies.

Fig. 1

Search Results. *as defined in Additional file 1

Fig. 2

Distribution of the different ways in which the clinical pathway is described in Cochrane reviews published between 2008 and July 2015 (n = 47)

Fig. 3

Clinical pathway of women with ≥ FIGO⁺ stage IB⁺ vulval cancer. +FIGO/IB International federation of Gynecology & Obstetrics classification; CT computed tomography; PET positron emission tomography; MRI magnetic resonance imaging; US ultrasound; FNA fine needle aspiration; IFL inguinofemoral lymphadenectomy. ++ Figure has been adapted from the following review entitled “Sentinel node (SN) assessment for diagnosis of groin lymph node involvement in vulval cancer (Review) The Cochrane Library 2014, Issue 6”

Fig. 4

Clinical pathway for emergency department identification of trauma-induced coagulopathy. **FFP fresh frozen plasma. ***Figure has been adapted from the following review entitled “Thromboelastography (TEG) and rotational thromboelastometry (ROTEM) for trauma induced coagulopathy in adult trauma patients with bleeding (Review). The Cochrane Library 2015, Issue 2”