Evidence-Based Medicine:

Diagnosis

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 EBM method (5 steps)
• Step 1: Assess your patient and determine the pertinent issues. You may be
looking for evidence about therapy options, prognosis or diagnostic
techniques.
• Step 2: Ask a clinical question. Use the PICO model to formulate a clear and
concise clinical question.
• Step 3: Acquire the best evidence. Search the appropriate
databases and resources to find the best evidence.
• Step 4: Appraise the evidence. Determine whether the information you found
is relevant, valid and applicable to your patient.
• Step 5: Apply the evidence to your patient. Ensure that the evidence and
recommendations meet your patient's values and expectations
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 EBM method (5 steps)

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 Clinical Scenario
• A 20 year old female student living in Yogyakarta came to the clinic
with a chief complaint of fever since four days ago. The doctor did a
lab test to detect the presence of IgM antibodies to the S. typhi
lipopolysaccharide antigen (TUBEX) and the result of the test was
positive. What is the probability that she really has typhoid infection?

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 Clinical Question
• What is the probability that a patient with a positiveTUBEX test result
really suffer from typhoid fever?

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 PICO
• Population/Patient: Typhoid Patient
• Intervention: IgM Antibodies
• Comparison: Blood culture
• Outcome: Sensitivity/Accuracy/Validity

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 Searching for articles

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 Searching for
articles

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 Selected article

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 Are the result of the study valid?

Primary guide:
• Was there an independent, blind comparison with a
reference standard?
• Did the patient sample include an appropriate spectrum of
patients to whom the diagnostic test will be applied in
clinical practice?

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Was there an independent, blind
comparison with a reference
standard?

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 Did the patient sample include an appropriate spectrum of patients
to whom the diagnostic test will be applied in clinical practice?

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 Are the result of the study valid?

Secondary guides:
• Did the result of the test being evaluated influence the
decision to perform the reference standard?
• Were the method for performing the test described in
sufficient detail to permit replication?

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 Did the result of test being evaluated influence the decision to
perform the reference standard?

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 Were the methods for performing the test described in
sufficient detail to permit replication?

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 What were the result?

• Are likelihood ratios for the test results presented or data

necessary for their calculation provided?
• Will the results help me in caring for my patient?
• Will the reproducibility of the test result and its
interpretation be satisfactory in my setting?

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 Results

Test Sensitivity (%) Specificity (%) PPV (%) NPV (%)

TUBEX-TF (n = 131) 100 94.12 63.16 100

OnSite Typhoid
IgG/IgM Combo (n = 100 94.34 63.16 100
136)

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 Uji Diagnosis

Sakit Tidak sakit

Tes positif a b a+b

Tes negatif c d c+d

a+c b+d a+b+c+d

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 Penampilan diagnosis
• Sensitivitas = a/a+c
• Spesifisitas = d/b+d
• Nilai ramal positif = a/a+b
• Nilai ramal negatif = d/c+d
• Akurasi = a+d/a+b+c+d

Rasio kemungkinan tes + = a/a+c : b/b+d

Rasio Kemungkinan tes - = c/a+c : d/b+d
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 2 Pendekatan ttg penampilan
diagnosis

Prevalensi Sensitivitas/
Nilai ramal
Spesifisitas

Pre-test Rasio Post-test

probability kemungkinan probability

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 Nomogram

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 Nomogram

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 Will the results help me in caring for my patient?

• Are the result applicable to my patient?

• Will the results change my management?
• Will patients be better off as a result of the test?

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 Will the result change my
management?
• “Test” threshold
• “Treatment” threshold
• Post test probability berapa perlu langsung treatment?
• Post test probability berapa perlu treatment atau pemeriksaan lain
untuk konfirmasi
• Untuk tes yg berurutan, jika dua tes sangat terkait, penggunaan tes
kedua memberikan sidikit informasi yg mengakibatkan hasil
misleading

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 Test-treatment
Test-treatment thresholds
thresholds

Do not test
Do not test

Test, & treat on the

basis of the test’s
results
Do not treat Get on with
treatment

0 .10 .20 .30 .40 .50 .60 .70 .80 .90

A B
Prevalence (pre-test probability) of target disoreder

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Will patient be better off as a result of the test?

• Kriteria uji diagnosis yang bermanfaat adalah ada tambahan informasi

yang mengakibatkan perubahan manajemen yang nantinya dapat
menguntungkan pasien
• Nilai dari pemeriksaan yang tepat tidak akan terbantahkan manakala
penyakit yang dimaksud membahayakan pasien jika tidak
terdiagnosis, memiliki risiko yang dapat diterima, dan tersedia
pengobatan yang efektif
• Tes yang akurat belum tentu memiliki dampak pada keluaran pasien.
Contoh kateterisasi jantung kanan pada pasien kritis

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 Clinical Question
• What is the probability that a patient with a positiveTUBEX test result
really suffer from typhoid fever?

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 Terima Kasih

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