EVIDENCE BASED

MEDICINE
EVALUATION ON
ARTICLES ON
DIAGNOSIS
EXCERPT from Painless Evidence Based Medicine by Dans, et. al, 2008
BY & JAOA 2007
JEUZ KOZ GELUZ
EDGAR CHYRUSS CRISOSTOMO
Journal Article

2
1
Appraising
Directness
 CLINICAL SCENARIO

E.T., a 19 year old, male, Filipino, single, with

unremarkable past medical history presented at the
emergency room with 5 days duration of distressing
cough, productive with yellowish sputum with on and
off low grade fever, undocumented.
 COMPONENTS OF THE STUDY PROBLEM
Among patients with acute respiratory
symptoms, how accurate is the C-reactive
protein in identifying pneumonia?
P Inclusion Criteria:
1. Adults > 18 years old admitted to the
emergency ward,
2. Respiratory symptoms (cough, sputum
production, dyspnea, tachypnea, and
pleuritic pain) as the main complaint,
with or without fever
3. Disease duration of less than 2 weeks.
E CRP
O Pneumonia
Exclusion Criteria:
1. Final diagnosis of acute decompensated
heart failure, pulmonary embolism, lung
cancer, or an upper respiratory infection
2. Severe immunosuppression or receiving
immunosuppressive therapy
3. No hospitalization required.
Determine the C-reactive protein levels
The study computed for the sensitivity,
specificity, and likelihood ratio.
2
Appraising
Validity
Question #1

▰ Was the reference standard an

acceptable one? Yes
Question #2

▰ Was the reference standard interpreted

independently from the test in question?
▰ Yes
3
Appraising
the Results
Question #1

▰ What were the likelihood ratios of the

various test results?
Results on Diagnostic Study

▰ Sensitivity
▰ Specificity
▰ Predictive Value
Two-way Results:
1. Researchers like to set cutoffs when tests have many results
2. Researchers like to ignore the meaning of intermediate results
 Results on Diagnostic Study

1. Sensitivity (sn) refers to the proportion of persons with disease who

correctly have a positive test, i.e. a/(a + c);
2. Specificity (sp) refers to the proportion of persons with no disease who
correctly have a negative test, i.e. d/(b + d).
3. Positive predictive value (ppv) is the proportion of persons with a positive
test who correctly turn out to have disease, i.e. a/(a + b);
4. Negative predictive value (npv) is the proportion of persons with a
negative test who correctly turn out to have no disease, i.e. d/(c + d).
 Results on Diagnostic Study

Probabilities are portions of the whole

Odds are the ratio of portions
Results on Diagnostic Study

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Results on Diagnostic Study

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4
Assessing
Applicability
Question #1

 Is the diagnostic test available and

affordable in the physician's clinical
setting?
 Yes
Points of Consideration

Biologic issues affecting Socioeconomic factors

applicability affecting applicability
▰ This include differences ▰ This includes disease
in sex, co-morbidity, difference and state of
race, age and health affecting middle
pathology. class and lower
socioeconomic class
5
Individualizing
Result
Pre-test Probability

While studies of diagnosis report the average effect of a test on

probability of disease, the effect may vary greatly from patient to
patient.
Pre-test Probability - is the individual’s baseline probability of
disease
Therapeutic threshold - is the probability of disease above which
we are willing to stop testing and just get on with therapy
Diagnostic threshold - is the probability of disease below which
we are willing to stop testing and just reassure the patient
Points of Consideration

1. When the test result will not lead to important changes in

probability
2. When effective treatment is unavailable for the disease you are
detecting, either because it is difficult to treat or the patient cannot
afford the treatment
3. Cost
4. Safety
5. Patient Preference
Pre-test Probability
Bayes Nomogram
6
Summary
 Likelihood Ratio

▰ Test results with LR > 1.0 increase the disease probability.

▰ Test results with LR < 1.0 decrease the disease probability.
▰ Test results with LR very close to 1.0 have little impact on your clinical or pre-test estimates
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of disease probability.