DECEMBER 20219· Reasonable likelihood of disease· Optimal diagnostic testing strategy · Impact on management and/or outcomeReasonable likelihood of diseasePrior to any intervention, it is essential that the clinician confirm the diagnosis or establish its pretest likelihood based on a complete evaluation of the patient. Imaging is especially helpful to confirm or exclude a diagnosis in patients with moderate to high clinical suspicion, but may not always be indicated in patients with a low or very low likelihood of disease. For example, the likelihood that an otherwise healthy patient with a migraine and a normal neurological exam will have a cause for their headache discovered on MRI is very low and no greater than the likelihood that a patient without any symptoms will have one present.Optimal diagnostic testing strategy Often there are several tests that can help to establish a diagnosis, each of which has advantages and drawbacks. A testing strategy defines when one test should occur before or after the other and is based on an assessment of both the benefits (increased diagnostic accuracy) and the risks. For example, a chest x-ray has good diagnostic accuracy and results in much less radiation exposure that a chest CT so should generally be performed first. Impact on management or outcomeThe results of the diagnostic test should provide information that allows the clinician to make a decision, impacting how the patient will be treated or not treated as the case may be. Ideally, this impact on treatment should improve the outcome of the patient. For instance, if a patient with back pain is going to be initially treated with physical therapy, imaging to confirm the presence of a disc herniation is unlikely to change the treatment plan. However if physical therapy or other conservative measures have failed to improve their pain, imaging is very helpful to determine the need for and type of surgery. In addition, adherence to guidelines has been tied to better outcomes.An appropriateness framework allows for the consideration of unique patient circumstances during the peer-to-peer review. Hence, clinical guidelines, when developed within a framework of appropriateness, are an excellent starting point to synthesize medical research and real world practice to facilitate the delivery of appropriate, safe and affordable care. Clinical guidelines, when developed within a framework of appropriateness, are an excellent starting point to synthesize medical research and real world practice to facilitate the delivery of appropriate, safe and affordable care
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