DIAGNOSTIK & SKRINING

Iwan Dwiprahasto
CE&BU
Fakultas Kedokteran UGM
(a) patients who underwent presurgical US and in
(b) patients who underwent appendectomy without prior US.
Puig et al, Radiology January 2003
 Natural History of Disease

Preclinical Clinical Outcome

A B C D E F
A. Biologic onset of the condition
B. Pathologic evidence of disease detectable by screening
C. Signs and symptoms of disease
D. Health care sought
E. Diagnosis of disease
F. Treatment of disease
 Issues in Screening

Definition

Early detection of preclinical disease in

asymptomatic persons

Purpose of screening

Improve outcomes of illness

Improve morbidity: example
Improve mortality: example
 Types of Screening

Primary prevention

Target: identifikasi faktor risiko pada individu yang

asymptomatik untuk mencegah perlangsungan penyakit lebih
lanjut.
E.g., diet & pengendalian BB untuk mencegah Type II
diabetes pada pasien early-stage impaired glucose
tolerance.
 Types of Screening

Secondary prevention

Target: mencegah proses penyakit untuk

memperbaiki prognosis

Menemukan pasien DM dg kadar gula tidak

terkontrol untuk mencegah komplikasi penyakit
microvascular (retinopathy dan nefropathy).
Tertiary prevention:

Target: individu yang telah mengalami

komplikasi, untuk memperbaiki prognosis

Pada penderita retinopati diabetikum, untuk

mencegah perdarahan retina dan kebutaan
 Diseases Appropriate for Screening

Serious consequences from disease

Reduce morbidity and/or mortality
E.g., breast cancer, phenylketonuria (PKU), gallstones?
Effective test available
E.g., hypertension, PKU, lung cancer?
Effective preclinical treatment available
E.g., uterine cancer, lung cancer, hypertension, prostate
cancer?
High prevalence of preclinical disease
E.g., breast cancer, bladder cancer, CVD?
Screening Recommended:
 MENGAPA TEST DIAGNOSTIK
DIPERLUKAN?
Rumit

Mahal

Invasif

Spesialistik

Interpretasi sulit
Test
canggih Hasil test negatif

Aksesibilitas rendah
 Diagnostic/screening

Highly sensitive/specific False positive/negative

Diagnostic/screening Misleading

Accurate

Best diagnostic tools

 PROSEDUR UJI DIAGNOSTIK

GOLD STANDARD

Pneumonia
Pneumonia
No
Pneumonia

Pneumonia
Respiratory No
rate Pneumonia
No
Pneumonia
 FOTO RONTGEN

No
Pneumonia Pneumonia

Pneumonia a b
RESPIRA
SI No
Pneumonia
c d

Sensitivit Specificit
y= y=
a / (a+c) d / (b+d)
 DEFINISI

Sensitivity:

Proporsi penderita yang sakit dan

memberikan hasil test positif

Spesificity

Proporsi orang tanpa penyakit

dan memberikan hasil test negatif
 FOTO RONTGEN

No
Pneumonia Pneumonia

+ PV =
Pneumonia a b a/ (a+b)
RESP
- PV =
I
RASI
No
Pneumonia
c d d/
(c+d)
 DEFINISI

Positive Predictive Value

probabilitas adanya penyakit pada

penderita dengan hasil test positif

Negative Predictive Value

probabilitas seseorang bebas dari penyakit

karena hasil test negatif
 streptococcus
+ -

+ 27 35 62
Dx
klinis
- 10 77 87

37 112 149

Se = 27/37 = Sp = 77/112 = 69%

73%
+PV= 27/62 = 43% -PV= 77/87 = 88%
 FOTO RONTGEN

No
Pneumonia Pneumonia

Pneumonia a b
RESPIRA
SI No
Pneumonia
c d

Accuracy = (a+d) /
N
Prevalence = (a+c) / N
 FOTO RONTGEN

No
Pneumonia Pneumonia

Pneumonia a b
RESPIRA
SI No
Pneumonia
c d

a/a + c c/a + c
LR + = ---------- LR - = ----------
b/b + d d/b + d
 Likelihood ratio positif:

probabilitas suatu hasil test positif pada

penderita yang sakit

Likelihood ratio negatif:

probabilitas suatu hasil test negatif pada

orang yang tidak sakit
 streptococcus
+ -

+ 27 35 62
Dx
klinis
- 10 77 87

37 112 149

27/37 10/37
LR+ = --------- = 2,3 LR- = ------- = 0,39
35/112 77/112
 MAKNA LIKELIHOOD RATIO

generate large, and often

>10 or < 0.1 conclusive changes from pre- to
post-test probability

generate moderate shifts in

5-10 and 0.1-0.2
pre- to post-test probability

generate small (but sometimes

2-5 and 0.5-0.2
important) changes in probability

alter probability to a small (and

1-2 and 0.5-1
rarely important) degree
LIKELIHOOD RATIO

Probabilitas suatu hasil test pada seorang penderita

dibandingkan dengan probabilitas hasil test pada
individu tanpa penyakit

Apa arti?

LR (+) = 12,3 LR (-) = 0,39

Figure 1. Classification algorithm for predicting bacteraemia in patients with acute
febrile illness (temperature 538C) in the first scenario (without use of laboratory
data). Physicians diagnosis of low-risk infective sites included acute pharyngitis,
acute bronchitis, acute diarrhoea, acute viral syndrome, pelvic inflammatory
disease, acute otitis media, acute sinusitis, and non-infectious processes.
Figure 2. Classification algorithm for predicting bacteraemia in patients with
acute febrile illness (temperature 538C) in the second scenario (with use of
laboratory data). Physicians diagnosis of low-risk infective sites included acute
pharyngitis, acute bronchitis, acute diarrhoea, acute viral syndrome, pelvic
inflammatory disease, acute otitis media, acute sinusitis, and non-infectious
processes. CRP, C-reactive protein.
Keuntungan likelihood ratio

Mudah mengklasifikasikan hasil test sebagai

normal & abnormal
Mengemas informasi yang terkandung dalam
hasil test pada derajat yang berbeda-beda
Pengambilan keputusan klinik untuk menentukan
perlu/tidaknya dilakukan test
Menggambarkan test performance
> bermakna untuk klinisi dibanding dengan
sensitivitas/spesifisitas: hanya 1 hasil, yaitu LR (+)
Is this evidence about a diagnostic test valid?

1. Was there an independent, blind

comparison with a reference (gold)
standard of diagnosis?
2. Was the diagnostic test evaluated in an
appropriate spectrum of patients (like
those in whom we would use it in
practice)?
3. Was the reference standard applied
regardless of the diagnostic test result?
4. Was the test (or cluster of tests) validated
in a second, independent group of
patients?
 1. Was there an independent, blind comparison with
a reference (gold) standard of diagnosis?

diagnostic test in question gold standard

history or autopsy or
physical examination, biopsy
a blood test

BLINDING
Is this evidence about a diagnostic test valid?
1. Was there an independent, blind
comparison with a reference (gold)
standard of diagnosis?
2. Was the diagnostic test evaluated in
an appropriate spectrum of patients
(like those in whom we would use it
in practice)?
3. Was the reference standard applied
regardless of the diagnostic test
result?
4. Was the test (or cluster of tests)
validated in a second, independent
group of patients?
 36 Ca colon/rectum 35
lanjut positif
Carcino Embryonic
Antigen (CEA) Ca colon/rectum
Derajat ringan
Akurasi
buruk
Ca gastrointes-
tinal lain

high

medium

low clinical suspicion

Is this evidence about a diagnostic test valid?
1. Was there an independent, blind
comparison with a reference
(gold) standard of diagnosis?
2. Was the diagnostic test evaluated
in an appropriate spectrum of
patients (like those in whom we
would use it in practice)?
3. Was the reference standard
applied regardless of the
diagnostic test result?
4. Was the test (or cluster of tests)
validated in a second,
independent group of patients?
 Was the reference standard applied regardless
of the diagnostic test result?

Standard Invasif Do more harm

NEGATIF Standard Non invasif Do more good

Was the test (or cluster of tests) validated in a
second, independent group of patients?

Disease (+)
Study Patiens
Disease (-)

Disease (+)
Independent
Group
Disease (-)
1. Is the dx test available, affordable,
accurate, and precise in our setting?

Tersedia

Terjangkau

Akurasi
EXPERT????
Presisi
2. Can we generate a clinically sensible estimate of our
patients pre-test probability?
From personal experience, prevalence statistics,
practice databases, or primary studies

pre-test probability
(apa yang kita pikirkan/duga sebelum test)

post-test probability
(apa yang kita pikirkan/duga setelah test)

Diagnostic tests that produce big changes from pretest to

post-test probabilities are important and likely to be useful
to us in our practice
2. Can we generate a clinically sensible estimate of our
patients pre-test probability?
Are the study patients similar to our own?
Is it unlikely that the disease possibilities or
probabilities have changed since this evidence was
gathered?

Widal Typhoid???

Appendisitis Mc Burney vs. USG

Hipertensi Kriteria hipertensi??