LEMBAR JAWABAN

SKILL LAB EVIDENCE BASED MEDICINE (EBM)

1. Dalam file excel tersedia DATA abnormalitas. Data abnormalitas terdiri dari variabel SGOT/SGPT
laki-laki, hemogoblin, trigliserid, total kolesterol, HDL, LDL. Hitunglah nilai abnormalitas dari data yang
tersedia

1.1 Hitung harga rerata

1.2 Hitung standar deviasi

1.3 Nilai abnormalitas adalah > rerata + 2x Standar deviasi

PARAMETER RERATA SD RERATA+2SD NILAI

ABNORMALITAS

1. SGOT/SGPT 26,29 13,923 26,29 + 2x13,923 54,136+0,05=54,19

= 54,136 Abnormal >54,19

2. Hb 12,472 0,3238 12,472 - 2x0,3238 11,83-0,05 = 11,78

= 11,83 Abnormal <11,78

3. TG 115,3 20,047 115 + 2x20,047 = 115,09+0,05=

115,094 155,14

4. Total Kolesterol 137,23 32,405 137,23 + 2x32,40 202,03+0,05=

= 202,03 202,08

5. HDL 89,44 17,119 89,44 - 2(17,119)= 55,22-0,05=55,17

55,22 Abnormal<55,17

6. LDL 74,64 13,634 74,64 + 2(13,63)= 101,9+0,05=101,95

101,9
Abnormal>101,95

Kenapa SD dikurang? Karena abnormalnya harus dibawah

Descriptive Statistics

N Minimum Maximum Mean Std. Deviation

SGOT/SGPT Laki-laki 200 1 49 26.29 13.923

Hemoglobin 200 12.0 13.0 12.472 .3238

Trigliserid 200 81 148 115.30 20.047

 Total Kolestrol 200 80 199 137.23 32.405

HDL 200 61 119 89.44 17.119

LDL 200 50 98 74.64 13.634

Valid N (listwise) 200

2. Tersedia Clinical Scenario sebagai berikut :

Patients presenting to Clinical doctor with a sore throat should not automatically be prescribed
antibiotics a many sore throat are non-bacterial in origin. The gold standard for diagnosing bacterial
sore throat is a throat swab and culture but this is expensive and time consuming. Clinical doctor
need a quick, easy diagnostic tool (e.g. a checklist or scorecard) to help them to decide whether a sore
throat is bacterial or non-bacterial in origin

Dari clinical skenario di atas buatlah :

2.1 Tabel Pico

P Patient with a sore throat

I Checklist or scorecard

C Throat swab and culture

O Accurate diagnosis

2.2 Buatlah Clinical Question

Clinical Question : In patient with a sore throat, is checklist or scorecard as accurate as throat swab
and culture for diagnosing bacterial infection?

2.3 Buatlah search term/ search/ keyword

Search term/search/key word : sore throat AND {CHECKLIST OR SCORECARD} AND throat swab AND
accurate diagnosis

sore throat AND {CHECKLIST OR SCORECARD} AND throat swab

2.4 Lakukan Searching

Searching : www.pubmed.gov

2.5 Paste kan abstrak artikel yang didapat pada lembar jawaban
Abstract
BACKGROUND:
OBJECTIVE:
To evaluate the usefulness of a clinical scorecard in managing sore throat in general practice.
DESIGN:
Validation study of scorecard for sore throat with a throat swab culture used as the 'gold standard'.
SETTING:
A solo family practice in rural New South Wales, AustraliaParticipants: Patients attending with sore
throat.
METHODS:
Patients from the age of 5 years and above presenting with the main symptom of a sore throat, and
who have not had any antibiotic treatment in the previous two weeks, were invited to participate in
the study. The doctor completed a scorecard for each patient participating and took a throat swab
for culture. Adult patients (> 16 yrs) were asked to complete a patient satisfaction questionnaire,
while guardians accompanying children (5 yr to < 16 yrs old) were asked to complete a similar,
guardian questionnaire.
MAIN OUTCOME MEASURES:
1. Ability of a new scorecard to differentiate between bacterial and non-bacterial sore throat.2.
Patients' trust in the scorecard.
RESULTS:
The scorecard has a sensitivity of 93.33%, a specificity of 63.16%, a positive predictive value of
50% and a negative predictive value of 96%. The sensitivity is better than other sore throat
scorecards that have been published but with a slightly lower specificity.There was a high level of
patient trust in the scorecard was (85.8% agreement). Patients also trusted their doctor's judgement
based on the scorecard (90.6% agreement).
CONCLUSIONS:
As the scorecard has a high sensitivity but only a moderate specificity, this means that it is more
reliable for negative results, i.e. when the result suggests a viral infection. When the result favours a
bacterial sore throat, then a high sensitivity can mean that there are a number of false positives.
GPs can be confident in withholding antibiotics when the scorecard indicates a viral infection.

2.6 Lakukan critical appraisal dari artikel dengan critical appraisal worksheet (Home Work)

DIAGNOSIS WORKSHEET

Citation: The usefulness of a clinical ‘scorecard’ in managing patients with sore

throat in general practice

Are the results of this diagnostic study valid?

Was there an independent, blind Yes, Validation study of scorecard for
comparison with a reference (“gold”) sore throat with a throat swab culture used
standard of diagnosis? as the ‘gold standard’.

Was the diagnostic test evaluated in an
appropriate spectrum of patients (like
those in whom it would be used in
practice)?
Was the reference standard applied
regardless of the diagnostic test result?
Was the test (or cluster of tests)
validated in a second, independent
group of patients?
Yes, Patients from the age of 5 years and
above presenting with the main symptom
of a sore throat, and
who have not had any antibiotic treatment
in the previous two weeks, were invited to
participate in the study.
Yes, The Centor criteria have provided the
most widely used and accepted scorecard
in America and in many other
countries

Are the valid results of this diagnostic study

important?

CALCULATIONS
Target disorder
(swab)

Bacteria Non-Bact Totals

l erial
Positiv 28 28 56
Diagnostic e a b a+b
test result
 (score Negativ 2 48 50
card)
e c d c+d

30 76 106
a+c b+d a+b+c+d
Totals

Sensitivity = a/(a+c) = 28/30 = 93%

Specificity = d/(b+d) = 48/76 = 63%
Likelihood ratio for a positive test result = LR+ = sens/(1-spec) = 93%/37% = 2.5
Likelihood ratio for a negative test result = LR - = (1-sens)/spec = 7%/63% = 0.1
Positive Predictive Value = a/(a+b) = 28/56 = 50%
Negative Predictive Value = d/(c+d) = 48/50 = 96%
Pre-test probability (prevalence) = (a+c)/(a+b+c+d) = 30/106 =28%
Pre-test odds = prevalence/(1-prevalence) = 28%/72% = 0.38

Post-test odds = pre-test odds  LR

Post-test probability = post-test odds/(post-test odds +1)

Can you apply this valid, important evidence about a diagnostic test in caring for
your patient?

Is the diagnostic test available, affordable, Yes

accurate, and precise in your setting?

Can you generate a clinically sensible Yes

estimate of your patient’s pre-test
probability (from personal experience,
prevalence statistics, practice databases, or
primary studies)?

 Are the study patients similar to your

own?

 Is it unlikely that the disease possibilities

or probabilities have changed since the
 evidence was gathered?

Will the resulting post-test probabilities Yes

affect your management and help your
patient?

 Could it move you across a

test-treatment threshold?

 Would your patient be a willing partner

in carrying it out?

Would the consequences of the test help Yes

your patient?

3. Dalam file excel tersedia DATA diagnostik. Data diagnostik terdiri dari variabel LDL dan kreatinin
kinase

3.1 Buatlah grafik titik potong diagnostik pastekan pada lembar jawaban
Buka medcalc, masukkan data, statsistik -> ROC curves --> plot versus

3.2 Perkirakan secara visual nilai titik potong diagnostik dan interpretasikan

Perkiraan nilai titik potong (cut of point) kreatinin kinase adalah 70

3.3 Hitunglah seluruh nilai diagnostik memakai MedCalc, Epicalc dan CAT Maker, buatlah
kesimpulan

ROC curve

Variable Kreatinin_kinase
Kreatinin Kinase

Classification variable MCI

MCI

Sample size 100

Positive group : MCI = 1 13

Negative group : MCI = 0 87

Disease prevalence (%) unknown

Area under the ROC curve (AUC)

Area under the ROC curve (AUC) 0,973

Standard Errora 0,0140

 b
95% Confidence interval 0,919 to 0,995

z statistic 33,901

Significance level P (Area=0.5) <0,0001

a
DeLong et al., 1988
b
Binomial exact

Youden index

Youden index J 0,9195

Associated criterion >69,1098

Criterion values and coordinates of the ROC curve

[Hide]

Criterion Sensitivity 95% CI Specificity 95% CI +LR -LR

≥40,0886 100,00 75,3 - 100,0 0,00 0,0 - 4,2 1,00

>69,1098 100,00 75,3 - 100,0 91,95 84,1 - 96,7 12,43 0,00

>70,1641 92,31 64,0 - 99,8 93,10 85,6 - 97,4 13,38 0,083

>72,9038 76,92 46,2 - 95,0 93,10 85,6 - 97,4 11,15 0,25

>73,2495 69,23 38,6 - 90,9 94,25 87,1 - 98,1 12,05 0,33

>75,2407 69,23 38,6 - 90,9 96,55 90,3 - 99,3 20,08 0,32

>76,5148 61,54 31,6 - 86,1 97,70 91,9 - 99,7 26,77 0,39

>76,8872 53,85 25,1 - 80,8 98,85 93,8 - 100,0 46,85 0,47

>77,4574 38,46 13,9 - 68,4 98,85 93,8 - 100,0 33,46 0,62

>77,995 30,77 9,1 - 61,4 100,00 95,8 - 100,0 0,69

>78,6751 0,00 0,0 - 24,7 100,00 95,8 - 100,0 1,00

Statistil -> ROC curves -> RoC curves -> centang yang dibawah kanan semua

69,1098 (Cut of point)

 kelompok kreatininkinase * MCI Crosstabulation

Count

MCI

MCI Negatif MCI Positif Total

kelompok kreatininkinase >=69.1098 9 13 22

<=69.1097 78 0 78

Total 87 13 100

Tables - 2-by-2 unstratified

11:05:45, 06/03/2019

| + - | Total

-------+-------------+-------

+ | 13 9 | 22

- | 0 78 | 78

-------+-------------+-------

Total | 13 87 | 100

Tests of significance

Fisher exact test (one tailed) : 0,000000

Fisher exact test (two tailed) : 0,000000

Uncorrected chi-square : 52,98

p-value : 0,000001

Yates corrected Chi-square : 47,88

p-value : 0,000001

Measures of exposure effect [95% CI]

Risk ratio : **** [****; ****]

Odds ratio : **** [****; ****]

Risk difference : 0,59 [0,39; 0,80]

Proportional attributable risk : **** [****; ****]

Population proportional attr. risk : **** [****; ****]

Vaccine efficacy [95% CI]

Vaccine efficacy : **** [****; ****]

Screening [95% CI]

Prevalence : 0,13 [0,07; 0,22]

Sensitivity : 1,00 [0,72; 0,99]

Specificity : 0,90 [0,81; 0,95]

Accuracy : 0,91 [0,83; 0,96]

Predictive value of +ve result : 0,59 [0,37; 0,79]

Predictive value of -ve result : 1,00 [0,94; 1,00]

Matched data

Z : 2,67

One-sided p-value : 0,003830

Two-sided p-value : 0,007661

McNemar Chi-square : 7,11

p-value : 0,007661

McNemar odds ratio [95% CI] : **** [1,69; 96,56]

Difference in proportions [95% CI] : 0,09 [0,03; 0,15]

Kelompok * Outcome Crosstabulation

Count

Outcome

Hidup Meninggal Total

Kelompok Ace Inhibitor 44 6 50

Placebo 37 13 50

Total 81 19 100

4. Dalam file excel tersedia DATA Therapy Bad Outcome

4.1 Hitunglah nilai-nilai Importance

Analyze - transform - cross tabs, masukan data ke stat_calc

CER = 0,26

EER = 0,12

RR = 0,46, artinya kelompok ACEi dengan kematian adalah 0,46 kali dibandingkan dengan kelompok
placebo. ACEi mengurangi risiko kematian pada MCI

ARR = 0,14, artinya apabila ACEi digunakan sebagai terapi maka selisih jumlah insidens kematian
antara ACEi dengan placebo sebesar 14%

RRR = 0,54, artinya apabila ACEi digunakan sebagai terapi maka insidens kematian MCI dapat
diturunkan sebesar 54% dari insidens sebelumnya

NNT 7,14 Dibutuhkan terapi ACE-inhibitor sebanyak antara 7-8 orang selama 2 tahun untuk mencegah
1 kematian pada pasien MCI

4.2 Buatlah Kesimpulan

Kesimpulan : hasil penelitian ini bermakna secara klinis

5. Dalam file excel tersedia DATA Therapy Effectiveness

5.1 Hitunglah nilai-nilai Importance

 Kelompok * Outcome Crosstabulation

Count

Outcome

Sembuh Tidak Sembuh Total

Kelompok Enalapril + ASA 26 24 50

Isossorbid Prodiprogrel +
9 41 50
Deuretik

Total 35 65 100

Hasil Interpretasi

CER = 0,18

EER = 0,52

RR = 2,89, peluang kesembuhan subjek pada kelompok terapi enalapril + ASA sebesar 2,88 kali
dibandingkan isosorbid + diuretik

ABI = 0,34, artinya selisih insiden sembuh antara enalapril + ASA dengan isosorbid + diuretik = 34%
RBI = 1,889, artinya apabila enalapril + ASA digunakan sebagai terapi maka insidens sembuh dapat
ditingkatkan sebesar 188,9% (secara klinis penggunaan enalapril + ASA sangat bermakna sebab RBI >
50%)

NNT = 2,94, artinya dibutuhkan terapi enalapril + ASA sebanyak antara 2-3 orang untuk
menyembuhkan 1 pasien MCI

5.2 Buatlah Kesimpulan

Kesimpulan : Hasil penelitian ini sangat bermakna