EBM diagnostic

Kanti Ratnaningrum

Analisi pada tes diagnostik
• Studi observasional  hubungan antar variabel
 prediktor & suatu penyakit

• Tes diagnostik : untuk menentukan kemampuan
suatu tes dalam membedakan orang yang
berpenyakit dan yang tanpa penyakit

• Indikator:
– Sensitifitas & spesifisitas
– Nilai duga/predictive value
– Rasio kecenderungan/Likelihood ratio
– ROC (Receiver operator characteristic) curve
2

Status
penykt
+ -
Hasil + a b
Test - c d

a= True positive
b = False positive
c = False negative
d = True negative

3

a d
Sensitifitas: Spesifisitas:
ac bd

Status
penykt
+ -
Hasil + a b
Test - c d

4

Nilai duga/ Predictive value/ Post probability PV + PV - Probabilitas bahwa Probabilitas bahwa orang dengan test + orang dengan test – adalah adalah benar-benar sakit benar-benar tidak sakit 5 .

= perbandingan antara kecenderunganorang tanpa penyakit mendapat hasil – dengan kecenderungan orang berpenyakit mendapat hasil - .• LR + = perbandingan antara kecenderungan seseorang yang berpenyakit akan mendapat hasil test + dengan kecenderungan seseorang tanpa penyakit mendapat hasil test + • LR .

= b d b+d b+d 7 . Status penykt + - Hasil + a b Test . c d a c a+c a+c LR + = LR .

Receiver operator characteristic curve/ ROC curve 100% sensitifitas 0 1 .spesitifitas 100% 8 .

Tujuan ROC cure 1. Menentukan nilai batas terbaik  makin mendekari pojok kiri atas makin baik 2. Membandingkan beberapa test  makin luas daerah di bawah curve makin baik .

untuk mempercepat diagnosis. Sakit tenggorokan dirasakan sudah lima hari.Skenario Klinis • Seorang anak laki-laki umur 10 tahun datang ke dokter dengan keluhan sakit tenggorokan. Hal ini membutuhkan pemeriksaan kultur bakteri tapi memerlukan waktu lebih dari satu hari. Yang menjadi fokus perhatian dokter adalah mendiagnosis pasien apakah faringitis ini disebabkan oleh streptokokus Grup A (GAS). Sebagian besar penyebab faringitis adalah virus. . dokter mempertimbangkan penggunaan pemeriksaan lain.

• Sebelum dokter mempertimbangkan perubahan alur diagnosis pasien faringitis.• Pemeriksaankultur merupakan “gold standrat” untuk mendiagnosis faringitis oleh karena GAS. Waktu yang diperlukan untuk pemeriksaan kultur ini sekitar 24-48 jam. • A quantitative polymerase chain reaction (qPCR) adalah teknik laboratorium biologi molekuler berdasarkan reaksi berantai polimerase ( PCR ) yang dapat sedang dikembangkan. sensitifitas qPCR dibandingkan dengan pemeriksaan kultur untuk mendeteksi GAS .

and applicability. Steps in Practicing EBM 1. . Integrate the evidence with our clinical expertise and our patient’s characteristics and values. Convert the need for information into an answerable question. 2. 4. 5. 3. Track down the best evidence with which to answer that question. impact. Critically appraise the evidence for its validity. Evaluating our effectiveness and efficiency in executing steps 1–4 and seeking ways to improve them both for next time.

The clinical question: PICO Patient or Interventi Comparis Outcome Problem on on Anak A Gold Diagnosis dengan quantitativ standard: of faringitis suspek e kultur e.c GAS Group A polymerase streptococc chain us (GAS) reaction (qPCR) .

Pertanyaan klinis • Pada pasien anak dengan suspek GAS yang dilakukan pemeriksaan qPCR dapat seakurat pemeriksaan kultur dalam membantu diagnosis? .

Track down the best evidence with which to answer that question. and applicability. impact. Evaluating our effectiveness and efficiency in executing steps 1–4 and seeking ways to improve them both for next time. . Critically appraise the evidence for its validity. Integrate the evidence with our clinical expertise and our patient’s characteristics and values. Steps in Practicing EBM 1. Convert the need for information into an answerable question. 5. 2. 4. 3.

ncbi.The search strategy • Pubmed database: (http://www.gov/sites/ent rez?db=pubmed) • Using the Clinical Queries function of PubMed: – Key words: • “GAS” AND • “qPCR” – Clinical Study Categories: “Diagnosis” – Scope: “Narrow” .nih.nlm.

biomedcentral. Gonis G. 2013. Marshall JL. The Evidence • Detection of group a streptococcal pharyngitis by quantitative PCR • Dunne EM. Steer AC. BMC Infectious Diseases 2013. Danchin MH. Baker CA. Satzke C. Manning J. Smeesters PH. 13:312 http:// www.com/1471-2334/13/31 2 . Detection of group a streptococcal pharyngitis by quantitative PCR.

Convert the need for information into an answerable question. 2. Integrate the evidence with our clinical expertise and our patient’s characteristics and values. . Steps in Practicing EBM 1. Evaluating our effectiveness and efficiency in executing steps 1–4 and seeking ways to improve them both for next time. Critically appraise the evidence for its validity. impact. 3. Track down the best evidence with which to answer that question. 4. and applicability. 5.

Can I apply this valid. important diagnostic test to a specific patient? Dapatkah saya mengaplikasikan diagnosis tes ini pada pasien saya (sesuai dengan spesifisitas)? . Is this evidence about the accuracy of a diagnostic test valid? Apakah bukti tentang akurasi tes diagnostik ini valid? 2. Does this (valid) evidence demonstrate an important ability of this test to accurately distinguish patients who do and do not have a specific disorder? Apakah ini (valid) bukti dapat menunjukkan kemampuan tes ini secara akurat dalam membedakan pasien yang sakit dan tidak sakit (dengan atau tanpa gangguan spesifik)? 2.Appraising the Evidence 1.

Can I apply this valid. important diagnostic test to a specific patient? . Is this evidence about the accuracy of a diagnostic test valid? 2. Does this (valid) evidence demonstrate an important ability of this test to accurately distinguish patients who do and do not have a specific disorder? 3.Appraising the Evidence 1.

Measurement/ pengukuran – Was the reference (“gold”) standard measured independently? – Apakah standar referensi (“baku emas") diukur secara independen? Ya (halm 2 dari 7) .Is this evidence about the accuracy of a diagnostic test valid? 1.

Is this evidence about the accuracy of a diagnostic test valid? 2. Representative – Was the diagnostic test evaluated in an appropriate spectrum of patients (those in whom we would use it in practice)? – Apakah tes diagnosis ini dievluasi pada spektrum pasien yang tepat (dapatkah diaplikasikan dalam praktek sehari-hari)? .

Is this evidence about the accuracy of a diagnostic test valid? 3. Ascertainment / proses pemastian – Was the reference standard ascertained regardless of the diagnostic test result? – Apakah hasil pada metode standar benar-benar berbeda dari tes diagnostik? (perbandingan kelompok) .

Kesimpulan 1 Are the results of this study valid? • Ya .

Appraising the Evidence 1. important diagnostic test to a specific patient? . Can I apply this valid. Is this evidence about the accuracy of a diagnostic test valid? 2. Does this (valid) evidence demonstrate an important ability of this test to accurately distinguish patients who do and do not have a specific disorder? 3.

. Positive Predictive Value = a/(a+b). Negative Predictive Value = d/(c+d). +d Specificity = d/(b+d). 2 x 2 Table Disease Totals Presen Absent t Diagnosti Positive a b a+b c Negativ c d c+d Test e Totals a+c b+d a+b+c Sensitvity = a/(a+c).

100= 100%  100% dari pasien yang dinyatakan (-) benar-benar tidak disebabkan oleh GAS . 100= 100%  benar-benar (+) GAS • Spesifisitas: 103/(0+103). Tabel 2x2 speB • Sensitifitas: 24/(24+0). 100= 100%  100% dari pasien yang dinyatakan (+) adalah benar disebabkan GAS • NPV: 103/(0+103).100= 100%  benar-benar (-) GAS • PPV: 24/(24+0).

100= 97%  97% dari pasien yang dinyatakan (-) benar-benar tidak disebabkan oleh GAS .100= 100%  benar-benar (-) GAS • PPV: 21/(21+0). 100= 87%  benar-benar (+) GAS • Spesifisitas: 103/(0+103). Tabel 2x2 spy1258 • Sensitifitas: 21/(21+3). 100= 100%  100% dari pasien yang dinyatakan (+) adalah benar disebabkan GAS • NPV: 103/(3+103).

More info: • Prevalensi carier faringitis GAS  12% (Shaikh N et al. 2010) • Sensitivitas dan spesifisitas tinggi vs prevalensi GAS 12%  berkontribusi ? .

Does this (valid) evidence demonstrate an important ability of this test to accurately distinguish patients who do and do not have a specific disorder? 3. important diagnostic test to a specific patient? . Can I apply this valid.Appraising the Evidence 1. Is this evidence about the accuracy of a diagnostic test valid? 2.

and precise in our setting? Apakah tes diagnostik ini yang tersedia. Is the diagnostic test available.Are the results of this diagnostic study applicable to my patient? 1. akurat. accurate. dan tepat digunakan pada kasus ini? • Ya. terjangkau. affordable. akurat dan tersedia (tetapi tidak di semua laboratorium) • Tetapi tidak terjangkau untuk semua pasien (hanya keluarga kalangan menengah ke atas) • Dan belum tepat dilakukan karena berbagai pertimbangan .

Are the study patients similar to our own? • Ya c. practice databases. Are the results of this diagnostic study applicable to my patient? 2. From personal experience. Is it unlikely that the disease possibilities have changed since this evidence was gathered? Apakah tidak mungkin bahwa kemungkinan penyakit telah berubah sejak bukti ini dikumpulkan? • Ya . prevalence statistics. Can we generate a clinically sensible estimate of our patient’s pre-test probability? Bisakah kita menghasilkan estimasi klinis yang masuk akal (sesuai) dari probabilitas pre-test pasien kami? a. • Ya b. or primary studies.

Likelihood Ratio SpeB • Likelihood Ratio+ = sens/(1-spec) = 100/(100-100) = ~ • Likelihood Ratio.3 • Post-test odds = pre-test odds x likelihood ratio = 23.= (1-sens)/spec = (100-100)/100 = 0 • Prevalence = (a+c)/(a+b+c+d) = 24/127 = 18.1 = 23.9/81.9% • Study pre-test odds = prevalence/(1-prevalence) = 18.3 x ~ = ~ • Post-test probability = post-test odds/(post-test odds +1) = ~ / ~ = ~ .

3 x ~ = ~ • Post-test probability = post-test odds/(post-test odds +1) = ~ / ~ = ~ .9% • Study pre-test odds = prevalence/(1-prevalence) = 18. Likelihood Ratio Spy1258 • Likelihood Ratio+ = sens/(1-spec) = 87/(100-100) = ~ • Likelihood Ratio.= (1-sens)/spec = (100-87)/100 = 13 • Prevalence = (a+c)/(a+b+c+d) = 24/127 = 18.9/81.3 • Post-test odds = pre-test odds x likelihood ratio = 23.1 = 23.

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Could it move us across a test-treatment threshold? Mungkinkah hasil post tes probabilitas menggeser ambang antara tes . Will the resulting post-test probabilities affect our management and help our patient? Mungkinkah probabilitas post-test mempengaruhi manajemen kami dan membantu pasien kami? 1. dari pre-test probability of 18.Are the results of this diagnostic study applicable to my patient? 3.pengobatan? • Ya.9% ke post-test probability of ~ .

jika hasil (-). Will the resulting post-test probabilities affect our management and help our patient? (cont.) 2. Would the consequences of the test help our patient reach his or her goals in all this? Apakah konsekuensi tes ini dapat membantu pasien kita mencapai tujuannya? • Ya. Would our patient be a willing partner in carrying it out? Apakah pasien kami bersedia melakukan tes ini? • Mungkin iya 3. jika hasil (+) dapat membantu dalam hal pengobatan dan pencegahan komplikasi seperti DRA dll .3.

Integrate the evidence with our clinical expertise and our patient’s characteristics and values. 5. . Steps in Practicing EBM 1. impact. Evaluating our effectiveness and efficiency in executing steps 1–4 and seeking ways to improve them both for next time. Convert the need for information into an answerable question. 3. 2. Critically appraise the evidence for its validity. and applicability. Track down the best evidence with which to answer that question. 4.

sehingga dapat digunakan untuk meningkatkan ketepatan diagnosis dan dan terapi serta mencegah komplikasi • Tes qPCR mungkin tidak efektif dari segi pembiayaan dan keterjangkauan karena tidak semua laboratorium memiliki fasilitas PCR ini • berbagai faktor harus dipertimbangkan sebelum penggunaan tes qPCR dalam strategi diagnosis. terapi dan pencegahan komplikasi . How can I apply the results to patient care? • Tes qPCR speB ini sangat bagus karena memiliki sensitifitas dan spesifitas tinggi.

and applicability. impact. . 4. Steps in Practicing EBM 1. Track down the best evidence with which to answer that question. 3. Convert the need for information into an answerable question. Evaluating our effectiveness and efficiency in executing steps 1–4 and seeking ways to improve them both for next time. Critically appraise the evidence for its validity. 5. Integrate the evidence with our clinical expertise and our patient’s characteristics and values. 2.

Terimakasih .