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Medical Decision Making
Medical Decision
Making
Third Edition
Harold C. Sox
Geisel School of Medicine at Dartmouth, Hanover, NH, USA
Michael C. Higgins
Stanford Center for Biomedical Informatics Research, Stanford University, Stanford, CA, USA
Douglas K. Owens
Department of Health Policy, School of Medicine, and Center for Health Policy, Freeman- Spogli Institute for International Studies,
Stanford University, Stanford, CA, USA
Gillian Sanders Schmidler
Department of Population Health Sciences, Medicine, and Duke-Margolis Institute for Health Policy, Duke University, Durham,
NC, USA
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This edition first published 2024
© 2024John Wiley & Sons Ltd
Edition History
Butterworth Publishers (1e, 1988); John Wiley & Sons, Ltd (2e, 2013)
All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by
any means, electronic, mechanical, photocopying, recording or otherwise, except as permitted by law. Advice on how to obtain
permission to reuse material from this title is available at http://www.wiley.com/go/permissions.
The right of Harold C. Sox, Michael C. Higgins, Douglas K. Owens, and Gillian Sanders Schmidler to be identified as the authors
of this work has been asserted in accordance with law.
Registered Offices
John Wiley & Sons, Inc., 111 River Street, Hoboken, NJ 07030, USA
John Wiley & Sons Ltd, The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, UK
For details of our global editorial offices, customer services, and more information about Wiley products visit us at www.wiley.com.
Wiley also publishes its books in a variety of electronic formats and by print- on- demand. Some content that appears in standard
print versions of this book may not be available in other formats.
Trademarks: Wiley and the Wiley logo are trademarks or registered trademarks of John Wiley & Sons, Inc. and/or its affiliates in
the United States and other countries and may not be used without written permission. All other trademarks are the property of
their respective owners. John Wiley & Sons, Inc. is not associated with any product or vendor mentionedin this book.
Limit of Liability/Disclaimer of Warranty
The contents of this work are intended to further general scientific research, understanding, and discussion only and are not
intended and should not be relied upon as recommending or promoting scientific method, diagnosis, or treatment by physicians
for any particular patient. In view of ongoing research, equipment modifications, changes in governmental regulations, and the
constant flow of information relating to the use of medicines, equipment, and devices, the reader is urged to review and evaluate
the information provided in the package insert or instructions for each medicine, equipment, or device for, among other things,
any changes in the instructions or indication of usage and for added warnings and precautions. While the publisher and authors
have used their best efforts in preparing this work, they make no representations or warranties with respect to the accuracy or
completeness of the contents of this work and specifically disclaim all warranties, including without limitation any implied
warranties of merchantability or fitness for a particular purpose. No warranty may be created or extended by sales representatives,
written sales materials or promotional statements for this work. The fact that an organization, website, or product is referred to in
this work as a citation and/or potential source of further information does not mean that the publisher and authors endorse the
information or services the organization, website, or product may provide or recommendations it may make. This work is sold
with the understanding that the publisher is not engaged in rendering professional services. The advice and strategies contained
herein may not be suitable for your situation. You should consult with a specialist where appropriate. Further, readers should be
aware that websites listed in this work may have changed or disappeared between when this work was written and when it is
read. Neither the publisher nor authors shall be liable for any loss of profit or any other commercial damages, including but not
limited to special, incidental, consequential, or other damages.
Library of Congress Cataloging-
in- Publication Data
Names: Sox, Harold C., author. | Higgins, Michael C. (Michael Clark),
1950–author. | Owens, Douglas K., author. | Sanders Schmidler, Gillian,
author.
Title: Medical decision making / Harold C. Sox, Michael C. Higgins, Douglas
K. Owens, Gillian Sanders Schmidler.
Description: Third edition. | Hoboken, NJ : Wiley-Blackwell, 2024. |
Includes bibliographical references and index.
Identifiers: LCCN 2023017110 (print) | LCCN 2023017111 (ebook) |
ISBN 9781119627807 (paperback) | ISBN 9781119627845 (adobe pdf) |
ISBN 9781119627722 (epub)
Subjects: MESH: Clinical Decision-Making | Diagnosis, Differential |
Decision Support Techniques
Classification: LCC RT48 (print) | LCC RT48 (ebook) | NLM WB 142.5 |
DDC 616.07/5–dc23/eng/20230703
LC record available at https://lccn.loc.gov/2023017110
LC ebook record available at https://lccn.loc.gov/2023017111
Cover Design: Wiley
Cover Image: © VectorKid/Shutterstock
Set in 9.5/12pt PalatinoLTStd by Straive, Pondicherry, India
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Dedications for Medical Decision Making, 3rd edition
To Jean and Kathleen
To Sara, Rachel, and Christopher
To Carol, Colin, and Lara
To Scott, Gib, Oliver, Edgar, and Irving
Their support has meant everything.
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vii
Contents
Foreword, xi
Preface, xiii
1 Introduction, 1
1.1
How may Ibe thorough yet efficient when considering thepossible causes ofmy patient’s problems?, 1
1.2
How do Icharacterize theinformation Ihave gathered during themedical interview
andphysical examination?, 1
1.3 How do Iinterpret new diagnostic information?, 3
1.4
How do Iselect theappropriate diagnostic test?, 4
1.5
How do Ichoose among several risky treatment alternatives?, 4
2 Differential diagnosis, 5
2.1 An introduction, 5
2.2
How clinicians make a diagnosis, 5
2.3 The principles of hypothesis- driven differential diagnosis, 8
2.4 An extended example, 14
Bibliography, 16
3 Probability: quantifying uncertainty, 18
3.1 Uncertainty and probability in medicine, 18
3.2
How todetermine aprobability, 21
3.3 Sources oferror inusing personal experience toestimate theprobability, 23
3.4 The role ofempirical evidence inquantifying uncertainty, 30
3.5 Limitations ofpublished studies ofdisease prevalence, 35
3.6 Taking thespecial characteristics ofthe patient into account when determining probabilities, 36
Bibliography, 37
4 Interpreting new information: Bayes’ theorem, 38
4.1 Introduction, 38
4.2
Conditional probability defined, 40
4.3 Bayes’ theorem, 41
4.4 The odds ratio form ofBayes’ theorem, 45
4.5 Lessons tobe learned fromusing Bayes’ theorem, 50
4.6 The assumptions ofBayes’ theorem, 52
4.7
Using Bayes’ theorem tointerpret asequence oftests, 54
4.8 Using Bayes’ theorem when many diseases are under consideration, 55
Bibliography, 57
5 Measuring theaccuracy ofclinical findings, 58
5.1 A language fordescribing test results, 58
5.2 The measurement ofdiagnostic test performance, 62
5.3 How tomeasure diagnostic test performance: ahypothetical example, 67
5.4
Pitfalls ofpredictive value, 69
5.5 How toperform ahigh quality study ofdiagnostic test performance, 70
5.6 Spectrum bias inthe measurement oftest performance, 74
5.7 When tobe concerned about inaccurate measures oftest performance, 79
5.8 Test results asa continuous variable: theROC curve, 81
5.9 Combining data fromstudies oftest performance: thesystematic review andmeta- analysis, 87
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viii Contents
A.5.1 Appendix: derivation ofthe method forusing anROC curve tochoose thedefinition ofan
abnormal test result, 89
Bibliography, 91
6 Decision trees– representing thestructure ofadecisionproblem, 93
6.1
Introduction, 93
6.2
Key concepts andterminology, 93
6.3
Constructing thedecision tree fora hypothetical decision problem, 96
6.4
Constructing thedecision tree fora medical decision problem, 103
Epilogue, 112
Bibliography, 112
7 Decision tree analysis, 113
7.1
Introduction, 113
7.2
Folding- back operation, 114
7.3
Sensitivity analysis, 126
Epilogue, 133
Bibliography, 133
8 Outcome utility– representing risk attitudes, 134
8.1 Introduction, 134
8.2 What are risk attitudes?, 135
8.3 Demonstration ofrisk attitudes ina medical context, 136
8.4 General observations about outcome utilities, 147
8.5 Determining outcome utilities– underlying concepts, 151
Epilogue, 157
Bibliography, 158
9 Outcome utilities– clinical applications, 159
9.1 Introduction, 159
9.2 A parametric model foroutcome utilities, 160
9.3 Incorporating risk attitudes into clinical policies, 172
9.4 Helping patients communicate their preferences, 181
Epilogue, 185
A.9.1
Exponential utility model parameter nomogram, 186
Bibliography, 188
10 Outcome utilities– adjusting forthe quality oflife, 189
10.1 Introduction, 189
10.2 Example– why thequality oflife matters, 190
10.3 Quality- lifetime tradeoff models, 193
10.4
Quality- survival tradeoff models, 203
10.5 What does it all mean?– anextended example, 209
Epilogue, 217
Bibliography, 217
11 Survival models: representing uncertainty aboutthelengthoflife, 218
11.1
Introduction, 218
11.2 Survival model basics, 219
11.3 Medical example– survival after breast cancer recurrence, 226
11.4
Exponential survival model, 228
11.5 Actuarial survival models, 232
11.6 Two- part survival models, 235
Epilogue, 247
Bibliography, 247
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