A Randomized Trial of Interval Likelihood Ratios for Clinical Decision-Making.

Abstract

Background: Dichotomized reporting of diagnostic test results may oversimplify test characteristics. Interval likelihood ratios (ILRs), test characteristics across a range of values, offer a nuanced alternative, but their impact on decision-making is uncertain. We assessed whether ILRs improve clinical decisions compared to two traditional formats: single-threshold and binary test characteristics.

Methods: We conducted a multicenter randomized trial of internal medicine residents, attending physicians, and advanced practice providers. Participants were presented with two fictional vignettes (cases involving pulmonary embolism diagnosis and heart failure treatment), each with a clearly correct response centered on a key diagnostic test result. The vignettes were identical except for participants' random assignment to one of three test characteristic presentations: (1) single threshold, (2) binary test characteristics, or (3) ILRs. We compared the correct management decision rates between the ILR and threshold groups and between the ILR and binary groups. Secondary objectives included comparing threshold and binary groups and subgroup analyses by case vignette.

Results: The trial enrolled 611 participants. The correct decision rate was 93.4% in the ILR group compared with 82.2% in the threshold group (difference of 11.2 percentage points; 95% confidence interval [CI], 6.9-15.6, P<0.001) and compared with 75.1% in the binary group (difference of 18.3 percentage points; 95% CI, 13.5-23.1, P<0.001). In the pulmonary embolism case, the correct response rate was 91.9% in the ILR group, 70.9% in the threshold group, and 64.7% in the binary group. In the heart failure case, the correct response rate was 94.9% in the ILR group, 93.4% in the threshold group, and 85.6% in the binary group.

Conclusions: Presenting diagnostic test information using ILRs improved vignette-based clinical decisions. The magnitude of improvement appeared to vary by case vignette.