EBM

PHASE 2 REVISION
 Basic flowchart of statistical tests

There are hundreds of statistical tests, and fortunately you don’t need to
know them all.

You can learn how to perform the most common tests on a computer stats
package.

You can also learn how to use flowcharts to determine which test to use.
This one is a very simple version (a good one to begin with).
 Basic flowchart of statistical tests
Is
Is your
your dependent
dependent variable
variable (outcome
(outcome measure)
measure) continuous?
continuous?

YES
YES NO
NO

Is
Is your
your independent
independent variable
variable continuous?
continuous? Is
Is your
your independent
independent variable
variable continuous?
continuous?

(e.g.,
(e.g.,22or
or33
YES
YES NO
NO groups)
groups) (e.g.,
YES NO (e.g.,22or
or33
YES NO groups)
groups)

Linear
Linear regression
regression Are
Are your
your groups
groups Are
similar/alike? Are your
your groups
groups
similar/alike? similar/alike?
NO
NO similar/alike?
NO
NO
YES
YES YES
YES
t-test
t-test YES
YES Do
Do you
you have
have only
only
22 groups?
groups? Logistic
Logistic regression
regression Chi-square
Chi-square test
test
ANOVA
ANOVA NO
NO
WHAT ARE THE RESULTS?

Reading the results aims at deciding whether the observed treatment

effect is worthy to change to the new treatment modality or not.
Reading the results can be done by considering the following points:

1. How significant and precise were the results?

 The significance of any differences between the groups should be discussed, with p-
values given to indicate statistical significance.

 The 95% confidence intervals should be also presented to demonstrate the degree of
precision of the results and what effect to be expected when applying the treatment
modality to the actual population.
 What is the real clinical value of the
treatment?
It is a golden statistical rule that statistical significance does not mean clinical
importance. Thus, not all statistically significant results are taken as clinically
important ones.

Thus, we need another method to evaluate the real importance of the new treatment.
This is done by calculating the absolute risk reduction (ARR) and the number needed to
treat (NNT) for the new treatment in comparison to the alternative one.
 WHAT ABOUT DIAGNOSTIC WORK?
Is The Study Valid?

1) Comparison with a reference (gold) standard of diagnosis?

2) Was the reference standard applied regardless of the diagnostic test result?
 Both the new diagnostic test and the gold standard should be performed to all participants independently;

3) Was the diagnostic test evaluated in an appropriate spectrum of patients (like those in whom it would be used in
practice)?
 A diagnosis study should include all disease spectrums present in the population (early, late, mild, and severe,
etc).
 EVALUATING THE RESULTS OF THE NEW
DIAGNOSTIC TEST

Is done by:
Sensitivity

Specificity

Positive predictive value of a test (PPV)

Negative predictive value of a test (NPV)

 SENSITIVITY AND SPECIFICITY

Sensitivity and specificity are used to describe the performance of the

screening test relative to the true disease status

“True” disease status is determined by the most definitive diagnostic

method, referred to as a “gold standard”.
 FORMAT FOR COMPARISON OF RESULTS OF A
DIAGNOSTIC TEST AGAINST THE “TRUE” DISEASE
STATUS

Gold standard
“Truth” Screening test
Total
No Disease Disease results

a +b b a Positive
False-positive True-positive
c+d d c Negative
True-negative False-negative
a+b+c+d b+d a+c Total
 The sensitivity of a test is defined as the percentage of persons with

the disease of interest who have positive test results. i.e., it is the

ability of the test to correctly identify those who are truly diseased.

Sensitivity is calculated as follows:

True positives (TP)

Sensitivity  X100
True positives (TP)  False negatives (FN)
a
 X100
ac
 The specificity of a test is defined as the percentage of persons
without the disease of interest who have negative test results. i.e., it
is the ability of the test to correctly identify those who are truly not
diseased.

Specificity is calculated as follows:

True negatives (TN)

Specificity  X100
True negatives (TN)  False positive (FP)
d
 X100
db
Example: The “gold standard” for breast cancer diagnosis is the
histopathological confirmation of cancer in a surgical specimen.

Screening test is mammography

To calculate how accurate is mammography test for detecting

breast cancer, screening test (mammography) results are
compared with findings from surgical excisional biopsies in
women without palpable breast masses.
COMPARISON OF MAMMOGRAPHY RESULTS WITH FINDINGS
FROM SURGICAL EXCISIONAL BIOPSIES IN WOMEN WITHOUT
PALPABLE BREAST MASSES

Gold standard
(Surgical biopsy)
Total Screening test
(Mammography)
No cancer Cancer

22 8 14 Positive
(b) (a)
92 91 1 Negative
(d) (c)
114 99 15 Total
 True positive (TP)
Sensitivity  X100
True positive (TP)  false negative (FN)
a 14
 X100  X 100  93%
ac 14  1

True negative (TN)

Specificity  X 100
True negatives (TN)  False positives (FP)
d 91
 X 100  X 100  92%
d b 91  8
 POSITIVE AND NEGATIVE PREDICTIVE
VALUE

Sensitivity and specificity describe the accuracy of a test.

Two measures that directly address the probability of disease are

the positive predictive value (PV+) and

the negative predictive value (PV -).
 Positive predictive value (PPV) is defined as the % of persons
with positive test results who are truly diseased

 The PPV estimates how likely the disease is present if the

test is positive.

 PPV is calculated as follows:

True positive (TP)

Positive predictive value  X 100
True Positives (TP)  False positives (FP)
a 14
 X 100  X 100  64%
ab 14  8
 Negative predictive value (NPV) is defined as the % of persons with
negative test results who are truly not diseased.

 NPV estimates how likely the disease is absent if the test is

negative.

 NPV is calculated as follows:

True negatives (TN)

Negative predictive value  X 100
True negatives (TN)  False negatives (FN)
d 91
 X100  X100  99%
d c 91  1