Defining the clinical pathway in cochrane diagnostic test accuracy reviews.
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.



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.



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.



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.
Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Academic Medical Center, University of Amsterdam, P.O Box 22660, 1100, Amsterdam, DD, The Netherlands. gowri.gkrishna@gmail.com.
G
G
Gopalakrishna
Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Academic Medical Center, University of Amsterdam, P.O Box 22660, 1100, Amsterdam, DD, The Netherlands.
Miranda W
MW
Langendam
Cochrane Netherlands, Julius Center - UMC Utrecht Huispostnummer Str. 6.131 Postbus 85500, 3508, Utrecht, GA, The Netherlands.
Rob J P M
RJ
Scholten
Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Academic Medical Center, University of Amsterdam, P.O Box 22660, 1100, Amsterdam, DD, The Netherlands.
Patrick M M
PM
Bossuyt
Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Academic Medical Center, University of Amsterdam, P.O Box 22660, 1100, Amsterdam, DD, The Netherlands.
Mariska M G
MM
Leeflang
D001778:Blood Coagulation Disorders / Q000175:diagnosis*; D003951:Diagnostic Errors; D006801:Humans; D015203:Reproducibility of Results; D012196:Review Literature as Topic
Clinical pathways; Cochrane systematic reviews; Diagnostic tests; Guidelines; Medical tests; Test accuracy studies