Interpretation of diagnostic data: 5. How to do it with simple maths.

The use of simple maths with the likelihood ratio strategy fits in nicely with our clinical views. By making the most out of the entire range of diagnostic test results (i.e., several levels, each with its own likelihood ratio, rather than a single cut-off point and a single ratio) and by permitting us to keep track of the likelihood that a patient has the target disorder at each point along the diagnostic sequence, this strategy allows us to place patients at an extremely high or an extremely low likelihood of disease. Thus, the numbers of patients with ultimately false-positive results (who suffer the slings of labelling and the arrows of needless therapy) and of those with ultimately false-negative results (who therefore miss their chance for diagnosis and, possibly, efficacious therapy) will be dramatically reduced. The following guidelines will be useful in interpreting signs, symptoms and laboratory tests with the likelihood ratio strategy: Seek out, and demand from the clinical or laboratory experts who ought to know, the likelihood ratios for key symptoms and signs, and several levels (rather than just the positive and negative results) of diagnostic test results. Identify, when feasible, the logical sequence of diagnostic tests. Estimate the pretest probability of disease for the patient, and, using either the nomogram or the conversion formulas, apply the likelihood ratio that corresponds to the first diagnostic test result. While remembering that the resulting post-test probability or odds from the first test becomes the pretest probability or odds for the next diagnostic test, repeat the process for all the pertinent symptoms, signs and laboratory studies that pertain to the target disorder. However, these combinations may not be independent, and convergent diagnostic tests, if treated as independent, will combine to overestimate the final post-test probability of disease. You are now far more sophisticated in interpreting diagnostic tests than most of your teachers. In the last part of our series we will show you some rather complex strategies that combine diagnosis and therapy, quantify our as yet nonquantified ideas about use, and require the use of at least a hand calculator.