Decision-Analytic Modeling to Evaluate Benefits and Harms of Medical Tests—Uses and Limitations

The clinical utility of medical tests is measured by whether the information they provide affects patient-relevant outcomes. To a large extent, effects of medical tests are indirect in nature. In principle, a test result affects patient outcomes mainly by influencing treatment choices. This indirectness in the link between testing and its downstream effects poses practical challenges to comparing alternative test-and-treat strategies in clinical trials. Keeping in mind the broader audience of researchers who perform comparative effectiveness reviews and technology assessments, we summarize the rationale for and pitfalls of decision modeling in the comparative evaluation of medical tests by using specific examples. Modeling facilitates the interpretation of test performance measures by connecting the link between testing and patient outcomes, accounting for uncertainties and explicating assumptions, and allowing the systematic study of tradeoffs and uncertainty. We discuss challenges encountered when modeling test-and-treat strategies, including, but not limited to, scarcity of data on important parameters, transferring estimates of test performance across studies, choosing modeling outcomes, and obtaining summary estimates for test performance data.