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Scenario 1: When Strong Evidence Agrees With Patient Preferences

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Making Informed Decisions for Better Health

Overview | Health Outcomes | EBM | Patient-centered Care | Informed Decisions | Examples | Talking to Your Doctor | Resources | Sources | Return to main article (use browser Back button)

Various factors can influence the decisions made and actions taken by patients and their healthcare practitioners regarding testing. No decision can be viewed as entirely clear-cut and the elements influencing decision-making can be seen as existing along a continuum among a spectrum of possibilities. Balancing these influences according to a given situation can be central to improving healthcare.

The following is the first set of examples in a series of three. Sometimes the scientific evidence is abundant and the answers are relatively clear as to whether a test is or is not useful and the testing protocol recommended by the medical community is consistent with a patient's needs and wishes.

Example one Evidence supports testing; tailoring the test for the individual patient improves outcome
Test A1c for monitoring diabetes
Desired outcome Fewer complications from diabetes
Evidence Good glycemic control lowers risk of complications
Standard care Use A1c to monitor glucose levels over time
Patient considerations Newly diagnosed can tolerate lower target, stricter control; if chronic, or with years of disease, loosen control, higher A1c target; some control better than no control
Healthcare improvement With more realistic glycemic control, avoid side effects like hypoglycemia, better compliance

Scientific evidence collected over years of practice indicates that diabetics who maintain a stable blood glucose level ("glycemic control") experience fewer complications. Good glycemic control is typically defined as an A1c less than 7%. More recently, evidence has supported individualized A1c targets rather than a one-size-fits all approach. A position statement published jointly by the American Diabetes Association and the European Association for the Study of Diabetes in 2012 supports this approach. Specifically, these groups have concluded that diabetics who are newly diagnosed can generally tolerate a lower target and stricter control. People who have lived with the disease for years, on the other hand, may require looser control with a higher A1c target, especially if they are at risk of low blood sugar (hypoglycemia). Adjusting the targets to fit an individual's requirement leads to better control and improved compliance. In this case, personalizing the testing, interpretation of results and subsequent adjustments to therapy obviously improves healthcare based on the evidence as well as from the patient perspective.

Example two Evidence is strong for testing; patient preferences matter greatly
Test Colon cancer screening
Desired outcome Lower incidence/fewer deaths from colon cancer
Evidence Colonoscopy = thorough screen and can remove precancerous polyps; FOBT only detects cancer, requires follow up if positive
Standard care Screen those 50 and older; patient chooses test
Patient considerations Individual preferences for different types of tests
Healthcare improvement More people at risk (>age 50) get screened

Several major healthcare organizations recommend that individuals age 50 and older undergo screening for colon cancer. The American Cancer Society, the U.S. Preventive Services Task Force, and the American Radiology Association, to name just a few, have guidelines supporting colon cancer screening. Though the advice may differ on which test to use and how often, these groups have found that screening lowers the incidence of this type of cancer and leads to fewer deaths. Recent technological advances have led to several possible testing options for detecting and/or preventing colon cancer. The choices for patients range from the fecal occult blood test (FOBT), an annual, non-invasive test requiring a sample that can be collected at home, to colonoscopy, an invasive imaging procedure that usually requires some level of sedation and may be performed every 5 to 10 years. Though the evidence is clear that screening can save lives, patient preferences can be the key to more people getting screened. (For more about colon cancer screening, see the articles for Adults and Adults 50 and Up)

Example three Evidence is strong against testing; patients willing to comply
Test Pap smear for cervical cancer screen in women under 21
Desired outcome Avoiding harms from testing for those who don't need it
Evidence Women younger than 21 rarely have cervical cancer
Standard care Unless family/medical history of cervical cancer, discourage testing
Patient considerations Patients are happy to forego unnecessary testing
Healthcare improvement Fewer false positives, less unnecessary testing

Let's face it, most people would like to avoid any medical procedures including testing; it is human nature to want to forego any inconvenience or unpleasantness if possible. In this third example, the evidence against testing nicely accommodates this patient preference. Several well-regarded health organizations including the American College of Obstetrics and Gynecology, the U.S. Preventive Services Task Force, and the American Cancer Society have evaluated years of evidence and now conclude that screening women younger than 21 for cervical cancer does not improve outcomes. This is because cervical cancer is rare in this age group. In fact, testing could worsen outcomes when testing results in false positives on Pap smears, leading to unnecessary follow-up testing and procedures. For this specific age group, the harms of testing outweigh the benefit, thus testing is discouraged, and patients younger than 21 are likely to comply because of a natural desire to avoid tests. On the other hand, women older than 21 are strongly urged to get tested. Read more about how and when to get tested in the screening articles for Young Adults, Adults, and Adults 50 and Up.

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