The impact of ordering investigations and getting normal test results on patients’ well being and health seeking behaviour – facilitated by Associate Professor Jane Smith

Background to the Issues

In primary care and secondary care tests are often ordered in patients without any clear diagnosis, or specific physical findings, as a triage tool “just in case” there may be something serious going wrong in a patient.  There is a presumption that ruling out a diagnosis by getting normal results back is a good thing.

But most patients with vague symptoms are unlikely to have a serious illness.

It is known that clinicians commonly order diagnostic tests in patients, with vague symptoms such as tiredness, with one study showing the majority of “tired patients” had tests done but they were abnormal in only 3% of them.(1)

This suggests that it is unlikely for testing in patients without specific diagnostic symptoms or signs, to show abnormal results, or a give a diagnosis.

Then what about the normal results reassuring the patient and doctor alike that nothing serious is going on, and that the patient is healthy?

The Paper: Reassurance after diagnostic testing with a low pretest probability of serious disease

This is a systematic review and meta-analysis of 14 RCTs published about the impact of normal diagnostic test results on patients’ illness worry, anxiety, ongoing symptoms, and health seeking behaviour.

The time spans analysed were less than 3 months (short term emotional relief) and more than 3 months (long term cognitive relief).

Inclusion criteria for participation were patients with a low risk of disease.(2)

Investigations included endoscopy and/or H pylori testing (for dyspepsia), ECG , blood tests or continuous event monitoring (for chest pain or palpitations respectively), imaging (for back pain or headaches).

Results

But the results suggest contrary to our clinical behaviour and beliefs, there is NO reassurance provided to patients by normal test results, in fact, some studies suggested an increase in anxiety resulted.

Regarding “health seeking” after investigations; The only changes found were that if 16 patients with dyspepsia were endoscoped, or 26 patients with low back pain had X rays, there would be one less visit to the doctor, at a cost of $4,000 to $16,000, plus irradiation to save $40-$100, this is a false economy.

Conclusions: Doing less achieves more.

References

  1. Gialamas A, Beilby JJ, Pratt NL, Henning R, Marley JE, Roddick JF. Investigating tiredness in Australian general practice. Do pathology tests help in diagnosis? Aust Fam Physician. 2003;32(8):663-6. Epub 2003/09/17.
  2. Rolfe A, Burton C. Reassurance after diagnostic testing with a low pretest probability of serious disease: systematic review and meta-analysis. JAMA Intern Med. 2013;173(6):407-16. Epub 2013/02/27.