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:
ac bd

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
 LR + = perbandingan antara
kecenderungan seseorang yang
berpenyakit akan mendapat hasil test +
dengan kecenderungan seseorang tanpa
penyakit mendapat hasil test +

LR - = perbandingan antara
kecenderunganorang tanpa penyakit
mendapat hasil dengan kecenderungan
orang berpenyakit mendapat hasil -
 Status
penykt
+ -
Hasil + a b
Test - c d

a c
a+c a+c
LR + = LR - =
b d
b+d b+d

7
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
Skenario Klinis
Seorang anak laki-laki umur 10 tahun datang ke
dokter dengan keluhan sakit tenggorokan. Sakit
tenggorokan dirasakan sudah lima hari. Sebagian
besar penyebab faringitis adalah virus. Yang
menjadi fokus perhatian dokter adalah
mendiagnosis pasien apakah faringitis ini
disebabkan oleh streptokokus Grup A (GAS). Hal
ini membutuhkan pemeriksaan kultur bakteri tapi
memerlukan waktu lebih dari satu hari, untuk
mempercepat diagnosis, dokter
mempertimbangkan penggunaan pemeriksaan
lain.
 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.
Sebelum dokter mempertimbangkan perubahan
alur diagnosis pasien faringitis, sensitifitas qPCR
dibandingkan dengan pemeriksaan kultur untuk
mendeteksi GAS
 Steps in Practicing EBM

1. Convert the need for information into

an answerable question.
2. Track down the best evidence with which to
answer that question.
3. Critically appraise the evidence for its
validity, impact, and applicability.
4. Integrate the evidence with our clinical
expertise and our patients characteristics
and values.
5. Evaluating our effectiveness and efficiency in
executing steps 14 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?
 Steps in Practicing EBM

1. Convert the need for information into an

answerable question.
2. Track down the best evidence with
which to answer that question.
3. Critically appraise the evidence for its
validity, impact, and applicability.
4. Integrate the evidence with our clinical
expertise and our patients characteristics
and values.
5. Evaluating our effectiveness and efficiency in
executing steps 14 and seeking ways to
improve them both for next time.
The search strategy
Pubmed database:
(http://www.ncbi.nlm.nih.gov/sites/ent
rez?db=pubmed)
Using the Clinical Queries function of
PubMed:
Key words:
GAS AND
qPCR
Clinical Study Categories: Diagnosis
Scope: Narrow
 The Evidence
Detection of group a streptococcal
pharyngitis by quantitative PCR

Dunne EM, Marshall JL, Baker CA, Manning

J, Gonis G, Danchin MH, Smeesters PH,
Satzke C, Steer AC. 2013. Detection of
group a streptococcal pharyngitis by
quantitative PCR. BMC Infectious Diseases
2013, 13:312 http://
www.biomedcentral.com/1471-2334/13/31
2
 Steps in Practicing EBM

1. Convert the need for information into an

answerable question.
2. Track down the best evidence with which to
answer that question.
3. Critically appraise the evidence for its
validity, impact, and applicability.
4. Integrate the evidence with our clinical
expertise and our patients characteristics
and values.
5. Evaluating our effectiveness and efficiency in
executing steps 14 and seeking ways to
improve them both for next time.
Appraising the Evidence
1. 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. Can I apply this valid, important diagnostic test to a
specific patient?
Dapatkah saya mengaplikasikan diagnosis tes ini pada pasien saya
(sesuai dengan spesifisitas)?
Appraising the Evidence
1. 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. Can I apply this valid, important
diagnostic test to a specific patient?
Is this evidence about the accuracy of a
diagnostic test valid?
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?
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. 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. Can I apply this valid, important
diagnostic test to a specific patient?
 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). +d
Specificity = d/(b+d).
Positive Predictive Value = a/(a+b).
Negative Predictive Value = d/(c+d).
 Tabel 2x2

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

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

Prevalensi carier faringitis GAS

12%
(Shaikh N et al. 2010)

Sensitivitas dan spesifisitas tinggi vs

prevalensi GAS 12%
berkontribusi ?
Appraising the Evidence
1. 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. Can I apply this valid, important
diagnostic test to a specific patient?
Are the results of this diagnostic study
applicable to my patient?

1. Is the diagnostic test available, affordable,

accurate, and precise in our setting?
Apakah tes diagnostik ini yang tersedia, terjangkau,
akurat, dan tepat digunakan pada kasus ini?

Ya, 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 results of this diagnostic
study applicable to my patient?
2. Can we generate a clinically sensible estimate of our
patients pre-test probability?
Bisakah kita menghasilkan estimasi klinis yang masuk akal (sesuai)
dari probabilitas pre-test pasien kami?
a. From personal experience, prevalence statistics, practice
databases, or primary studies.
Ya
b. Are the study patients similar to our own?
Ya
c. 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
 Likelihood Ratio

SpeB
Likelihood Ratio+ = sens/(1-spec) = 100/(100-100) = ~
Likelihood Ratio- = (1-sens)/spec = (100-100)/100 = 0
Prevalence = (a+c)/(a+b+c+d) = 24/127 = 18.9%
Study pre-test odds = prevalence/(1-prevalence) = 18.9/81.1 = 23.3
Post-test odds = pre-test odds x likelihood ratio = 23.3 x ~ = ~
Post-test probability = post-test odds/(post-test odds +1) = ~ / ~ = ~
 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%
Study pre-test odds = prevalence/(1-prevalence) = 18.9/81.1 = 23.3
Post-test odds = pre-test odds x likelihood ratio = 23.3 x ~ = ~
Post-test probability = post-test odds/(post-test odds +1) = ~ / ~ = ~
Are the results of this diagnostic
study applicable to my patient?

3. 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. Could it move us across a test-treatment threshold?

Mungkinkah hasil post tes probabilitas menggeser
ambang antara tes - pengobatan?

Ya, dari pre-test probability of 18.9% ke post-test

probability of ~
3. Will the resulting post-test probabilities
affect our management and help our
patient? (cont.)
2. Would our patient be a willing partner in
carrying it out?
Apakah pasien kami bersedia melakukan tes ini?
Mungkin iya
3. 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, jika hasil (-), jika hasil (+) dapat membantu
dalam hal pengobatan dan pencegahan komplikasi
seperti DRA dll
 Steps in Practicing EBM

1. Convert the need for information into an

answerable question.
2. Track down the best evidence with which to
answer that question.
3. Critically appraise the evidence for its
validity, impact, and applicability.
4. Integrate the evidence with our clinical
expertise and our patients
characteristics and values.
5. Evaluating our effectiveness and efficiency in
executing steps 14 and seeking ways to
improve them both for next time.
 How can I apply the results to
patient care?
Tes qPCR speB ini sangat bagus karena memiliki
sensitifitas dan spesifitas tinggi, 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
 Steps in Practicing EBM

1. Convert the need for information into an

answerable question.
2. Track down the best evidence with which to
answer that question.
3. Critically appraise the evidence for its
validity, impact, and applicability.
4. Integrate the evidence with our clinical
expertise and our patients characteristics
and values.
5. Evaluating our effectiveness and
efficiency in executing steps 14 and
seeking ways to improve them both for
next time.
Terimakasih