NURS310 PUBLIC HEALTH &

CLINICAL EPIDEMIOLOGY
Department of Nursing Education, School of Science & Technology
THE UNIVERSITY OF THE SOUTHERN CARIBBEAN

Unit 3 Chapter 3
Abnormality

Slide Credits:
Content/Notes and Design: K. Barker
 NURS310 PUBLIC HEALTH &
CLINICAL EPIDEMIOLOGY
03
Unit 3 Chapter 3
Abnormality

OBJECTIVES At the end of the lesson, students will be able to:

01 Explain how how clinical phenomena are measured

(types of data)

Discuss how one describes the performance of

02 measurements

03 Explain variation in clinical measurements

04 Discuss the criteria for what is considered “abnormal"

“...for those who love God all things work together for good, for
those who are called according to His purpose.”
Romans 8:28 KJV
Unit 3 Chapter 3
Abnormality
Introduction

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ABNORMALITY
Clinicians spend a great deal of time distinguishing “normal” from
“abnormal” and often have to make subtle distinctions between the two.
e.g. In primary care settings and emergency departments, patients
with subtle manifestations of disease are mixed with those with the
everyday complaints of basically healthy people.

Observations that are determined “normal” are usually described as

“within normal limits,”
“unremarkable,” or
“non-contributory”

This can result in some misclassification.

Unit 3 Chapter 3
Abnormality

Although crude, a patient’s

problem list serves as a basis for
decisions about clinical decisions –
diagnosis, prognosis, and
treatment

This can be
• actively (by additional
diagnostic tests and treatment)
or
• passively (by no intervention)
Unit 3 Chapter 3
Abnormality
Objective 01

TYPES OF DATA
Measurements of clinical phenomena yield three kinds of data:
1. Nominal
2. Ordinal
3. Interval

Ordinal and interval data seek to answer the question,

“Where does normal end and abnormal begin?”
Unit 3 Chapter 3
Abnormality

TYPES OF DATA
1. Nominal Data
Occur in categories without any inherent order, i.e. there is no ranking or
scale of the data

Examples:
• Blood types – ABO
• Sex – male, female, non-binary
• Treatment/Outcome – Dialysis, surgery, death

Nominal data that are divided into two categories

(e.g., present/absent, yes/no, alive/dead)
are called dichotomous.
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Abnormality

TYPES OF DATA
2. Ordinal Data
Possess some inherent ordering or rank such as small to large or good to
bad, but the size of the intervals between categories is not specified.

Examples
• Heart murmurs – Grades I to VI
• I – heard only with special effort
• VI – audible with the stethoscope off the chest
• Muscle strength – Grades 0 to 5
• 0 – no movement
• 5 – normal strength
Unit 3 Chapter 3
Abnormality

TYPES OF DATA
3. Interval Data
Possess inherent order and the interval between successive values is
equal

Example: measurements

Two types of interval data:

• Continuous data
• Discrete data
Unit 3 Chapter 3
Abnormality

TYPES OF DATA
3. Interval Data
Continuous Data
Can take on any value in a continuum or range (can be fractions), regardless
of whether they are reported that way

Examples:
• Most serum chemistries
• Weight
• Blood pressure

The measurement and description of continuous

variables may be confined to a limited number of
points (e.g. simplified or rounded off)
> blood glucose reading of 193.2846573 mg/dL
reported as 193 mg/dL.
Unit 3 Chapter 3
Abnormality

TYPES OF DATA
3. Interval Data
Discrete Data
Can take on only specific values, and are expressed as counts/integers.

Examples:
• Number of patients on a ward
• Number of a woman’s pregnancies and live births
• Number of migraine attacks a patient has in a month
(cannot have ½ a patient, ¼ migraine etc.)
Unit 3 Chapter 3
Abnormality
Objective 02

PERFORMANCE OF MEASUREMENTS
Whatever the type of measurement, its performance can be described in
several ways:

• Validity
• Reliability
• Range
• Responsiveness
• Interpretability
Unit 3 Chapter 3
Abnormality

PERFORMANCE OF MEASUREMENTS
Validity
a.k.a. Accuracy
The degree to which the data measure what they were intended to measure
i.e. the degree to which the results of a measurement correspond to
the true state of the phenomenon being measured

To establish validity, the observed measurement is compared with some

accepted standard.
e.g. recently calibrated instruments, high and low standards for lab
measurements, structured interviews/questionnaires

TRUTH

RESULT
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Abnormality

PERFORMANCE OF MEASUREMENTS
Three general strategies are used to establish the validity of measurements
that cannot be directly verified physically.

(a) Content Validity

• Assesses whether a test is representative of all aspects of the concept
or characteristic being measured
• The extent to which a particular method of measurement includes all of
the dimensions of the construct one intends to measure and nothing
more.

e.g. A scale for measuring pain would have content validity

if it included questions about aching, throbbing,
pressure, burning, and stinging,
but not about itching, nausea, and tingling
Unit 3 Chapter 3
Abnormality

PERFORMANCE OF MEASUREMENTS
(b) Criterion Validity
Assesses how closely the results of your test correspond to the results of a
different test.

e.g. One might see whether responses on a scale measuring pain bear a
predictable relationship to pain of known severity:
Mild pain from minor abrasion,
Moderate pain from ordinary headache,
Severe pain from renal colic
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Abnormality

PERFORMANCE OF MEASUREMENTS
(c) Construct Validity
Ensures that the method of measurement matches the construct (concept
or characteristic that is not physically verifiable) that you want to measure

e.g. There is no objective, observable entity called “depression” that we can

measure directly. However, based on existing psychological research and
theory, we can measure depression based on a collection of symptoms and
indicators, such as low self-confidence and low energy levels.
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Abnormality

Validity
Content Validity Criterion Validity Construct Validity
Do the results Is the test fully Does the test measure
correspond to a representative of what the concept that it is
different test of the it aims to measure? intended to measure?
same thing?
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PERFORMANCE OF MEASUREMENTS
Reliability
a.k.a. Reproducibility / Precision
The extent to which repeated measurements get similar results if done by
different people and instruments at different times and places.

To establish reliability, the observed measurement is repeated to show that

they
are similarly described to different observers under different conditions
e.g. repeated measurements of the same serum or tissue specimen –
sometimes by different people and with different instruments

REPEATED RESULTS
 Unit 3 Chapter 3
Abnormality

PERFORMANCE OF MEASUREMENTS
Validity and Reliability are not altogether independent concepts.
In general, an unreliable measurement cannot be valid and a valid
measurement must be reliable.

TRUTH

RELIABLE NOT RELIABLE RELIABLE

but not and and
VALID NOT VALID VALID
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Abnormality

PERFORMANCE OF MEASUREMENTS
Range
The scope/extent to which values of a phenomenon are measured and
convey information.

e.g. Basic Activities of Daily Living scale that measures patients’ ability in
dressing, eating, walking, maintaining hygiene etc. does not measure
ability to read, write, or play an instrument (activities that might be very
important to individual patients).

An instrument that does not register very low or high

values of the phenomenon is said to have limited range,
which limits the information it conveys.
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Abnormality

PERFORMANCE OF MEASUREMENTS
Responsiveness
The ability to detect change over time, or the extent to which an
instrument’s results change as conditions change.

e.g. ECG
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PERFORMANCE OF MEASUREMENTS
Interpretability
Clinicians learn to interpret the significance of a measurement or result
through experience, by repeatedly calibrating patients’ conditions and
clinical courses.

Scales based on questionnaires may have little intuitive meaning to

clinicians and patients who do not use them regularly. To help clinicians
interpret scale values, the numbers are anchored to descriptions.

e.g. Values of the Karnofsky Performance Status Scale

(a measure of functional capacity), range from 100 to 0.

Within this range, levels of capacity are assigned to

numbers: 100 (normal) to 0 (dead)
Unit 3 Chapter 3
Abnormality
Objective 03

VARIATION
Measurement Variation Biologic Variation
Overall = (related to the act + (differences within individuals
variation from time to time,
of measurement)
and among individuals)
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Abnormality

VARIATION
All observations are subject to variation because of the performance of
the instruments and observers involved in making the measurements.

The conditions of measurement can lead to:

• Biased results (lack of validity) or
• Random error (lack of reliability)

To reduce variation:
• Measure with great care
• Follow standard protocols
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Abnormality
Objective 04

CRITERIA FOR ABNORMALITY

Various genetic abnormalities coding for the same disease produce a range
of expressions. Even the expression of one specific genetic abnormality
differs substantially from one person to another.

Therefore, most distributions of clinical variables are not easily divided into
“normal” and “abnormal.”

The following slides explain some ways to classify abnormality.

Unit 3 Chapter 3
Abnormality
Objective 04

CRITERIA FOR ABNORMALITY

Unusual
One common way of establishing a cut-off point between normal and
abnormal is to use the statistical definition of normality -
i.e. that all values beyond 2 standard deviations from the mean are
abnormal
In other words – if it deviates too much from the average/usual

However, this approach can be ambiguous or misleading.

Standard deviation – The absolute value of the average

difference of individual values from the mean.
Click here for a video explanation
Unit 3 Chapter 3
Abnormality

CRITERIA FOR ABNORMALITY

Associated with Disease
A sounder approach to distinguishing normal from abnormal is to call
abnormal those observations that are clinically meaningful departures from
good health
i.e. associated with a meaningful risk of having or developing disease,
disability, or death

However, this approach can sometimes lead to different levels of a condition

being abnormal.
Unit 3 Chapter 3
Abnormality

CRITERIA FOR ABNORMALITY

Treating the Condition Leads to a Better Clinical Outcome
Treatment of the condition makes a difference. This approach makes
particularly good sense for asymptomatic conditions.

Modern technology, especially newer imaging techniques, are now able to

detect abnormalities in patients so well that it is not always clear what is
found is related to the patient’s complaint.
Unit 5.2 Chapter 8
Abnormality

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Self-directed Study
Complete the Review
Questions at the end of
Chapter 3
THANK YOU
Questions?
REFERENCES

Fletcher, R. & Fletcher, S. Clinical Epidemiology: The Essentials. (Latest

Edition). Lippincott Williams & Wilkins