Professional Documents
Culture Documents
CLINICAL GUIDELINES
Clinical guidelines often make recommendations on the bleeding. During the course of the group’s
use of diagnostic tests. Compared with sensitivity and deliberations we were struck by the discomfort
expressed by other group members and the target
specificity, the use of pre- and post-test probabilities audience (mainly encompassing gynaecologists,
allows a more explicit and rational selection and radiologists and general practitioners) when
interpretation of diagnostic tests. Ideally, clinical “newer” approaches to understanding diagnostic
tests were introduced. This paper draws on our
guidelines relating to diagnosis should routinely deliberations to demonstrate how the develop-
incorporate this information to enhance individualised ment of diagnostic recommendations within
decision making. We report our experience of clinical guidelines can be improved and high-
lights potential difficulties with their application.
incorporating pre- and post-test probabilities into a
guideline on the investigation of women with LIMITATIONS OF SENSITIVITY AND
SPECIFICITY IN THE CLINICAL
postmenopausal bleeding developed by the Scottish ENCOUNTER
Intercollegiate Guidelines Network. Issues relating to Postmenopausal bleeding represents one of the
their application are highlighted, including the most common reasons for referral to gynaecologi-
cal services, largely because of the need to detect
limitations of available evidence on diagnostic tests and or exclude endometrial carcinoma. The most rig-
prevalence of disease, acceptability to guideline users, orously evaluated investigation is transvaginal
and the uncertain impact on actual clinical decision ultrasonography9 10 which measures endometrial
thickness. The diagnostic rationale is that, for an
making. Despite these potential difficulties, the individual woman, the greater the measured
incorporation of data on pre- and post-test probabilities endometrial thickness, the higher the probability
into the development and presentation of guideline that cancer is present. Transvaginal ultrasonogra-
phy is attractive as an initial investigation as it is
recommendations may offer an important opportunity to non-invasive and well tolerated. Sufficient reas-
make clinical decision making more transparent for both surance from a negative result can help avoid
clinicians and patients. unnecessary and more invasive procedures seek-
ing a tissue diagnosis. The Guideline Develop-
..........................................................................
ment Group had to decide whether or not to rec-
ommend the use of this as a first line test and, if
C
linical guidelines are “systematically devel- so, what diagnostic threshold to recommend.
oped statements to assist practitioner and Although transvaginal ultrasonography ob-
patient decisions about appropriate health tains an actual measurement of endometrial
care for specific clinical circumstances”.1 Guide- thickness, test results are typically reported
lines often make recommendations on the use of simply as “positive” or “negative” depending on
diagnostic tests. Parameters essential to the whether the thickness is above or below a
evaluation of diagnostic test performance, such as specified threshold. In such circumstances, per-
sensitivity and specificity, are neither intuitive nor formance of the diagnostic test across the study
readily transferable to clinical situations.2 Much group is usually summarised in terms of sensitiv-
has been written highlighting the superiority of ity and specificity. Sensitivity is the probability of
likelihood ratios in providing information more testing positive if the disease is truly present.
relevant to clinical decisions concerning indi- Specificity is the probability of testing negative if
vidual patients,3–7 yet these parameters are seldom the disease is truly absent.
presented in clinical guidelines. The Scottish Box 1 presents an illustrative example of a
Intercollegiate Guideline Network (SIGN) guide- woman referred to a gynaecology outpatient
See end of article for
lines are developed by multidisciplinary groups department for assessment of postmenopausal
authors’ affiliations according to rigorous criteria, including explicit bleeding. She and her general practitioner were
....................... methods of appraising evidence and grading concerned about the possibility of endometrial
recommendations.8 None of 17 SIGN guidelines cancer. Transvaginal ultrasound was performed
Correspondence to:
R Foy, Centre for Health published between 1996 and 2001 which dealt using a threshold of >5 mm to define abnormal
Services Research, substantially with diagnostic processes men- endometrial thickening. Based upon findings
University of Newcastle tioned the use of likelihood ratios in the develop- from a recent meta-analysis, transvaginal ultra-
upon Tyne, Newcastle ment of recommendations. sonography using this threshold has a sensitivity
upon Tyne NE2 4AA, UK;
R.C.Foy@ncl.ac.uk We were members of a SIGN guideline develop- of 91% and specificity of 58% for the detection of
ment group that addressed the selection and endometrial carcinoma.10 On hearing her test
Accepted for publication interpretation of diagnostic procedures for the result was negative, the woman questioned her
23 March 2003
.......................
assessment of women with postmenopausal gynaecologist:
www.qshc.com
206 Foy, Warner
www.qshc.com
Diagnostic guidelines 207
www.qshc.com
208 Foy, Warner
Figure 1 Summary of recommendations in the Quick Reference Guide from the SIGN guideline on the investigation of postmenopausal
bleeding (PMB).30
www.qshc.com
Diagnostic guidelines 209
www.qshc.com