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Screening
Screening
“...the identification of unrecognized disease or defect by the application of tests, examinations or other procedures...”
“...sort out apparently well persons who probably have disease from those who probably do not.”
“...not intended to be diagnostic...”
Types of screening
• Mass screening, no selection of population (e.g., checking all infants for hearing problems)
• Selective screening (e.g., by age and sex: mammograms for women aged over 40)
• Multiphasic screening (a series of tests, as family doctors do at annual health exams)
When should we screen?
Screen when:• It is an important health problem (think about how to
define ‘important’?)• There is an accepted and effective treatment• Disease has a recognizable latent or early symptomatic
stage• There are adequate facilities for diagnosis and treatment• There is an accurate screening test• There is agreement as whom to consider as cases
Characteristics of a good screening test
• Valid (e.g., sensitive and specific)• Reliable (gives consistent results; no random errors)• Cost – benefit (compare costs avoided due to early
detection of the disease against cost of the screening. Does the test merely uncover more disease that is expensive to treat without appreciable advantage?)
• Acceptable (discomfort, invasiveness, cost of obtaining test)
• Follow-up services (plan needed to deal with positive results)
Validity – get the correct result
Sensitivity
Specificity
Predictive values
Reliable – get same result each time
How good is the test?
What is used as a “gold standard”
1. Most definitive diagnostic procedure e.g. microscopic examination of a tissue specimen
2. Best available laboratory teste.g. polymerase chain reaction (PCR)
for HIV virus
3. Comprehensive clinical evaluatione.g. clinical assessment of arthritis
8
Sensitivity and specificity
Assess correct classification of:
• Sensitivity means probability of having a positive test results among those with disease
• Specificity means probability of having a negative test results among those without the disease (specificity)
Truepositive
Truenegative
Falsepositive
Falsenegative
Sensitivity = True positives
All cases
a + c b + d
= aa + c
Specificity = True negatives All non-cases
= db + d
a + b
c + d
True Disease Status
Cases Non-cases
Positive
Negative
ScreeningTest
Results
a d b
c
X 100
X 100
10
True Disease Status
Cases Non-cases
Positive
Negative
ScreeningTest
Results
a d
1,000 b
c60
Sensitivity = True positives
All cases
200 20,000
= 140200
Specificity = True negatives All non-cases
= 19,00020,000
1,140
19,060
140
19,000
=
= 70%
95%
Uses of sensitive test:
1. In emergency department.2. In screening.3. In diseases with low frequency.4. In highly serious communicable disease.* Best use of sensitive test when test result is –v.
Uses of specific test:
1. Chronic cases as in wards and clinic.2. To confirm the diagnosis.3. When the treatment is harmful as cytotoxic drugs.4. When cost of treatment is very high.* Best use of specific test when test result is +v.
12
Interpreting test results: predictive value
Probability (proportion) of those tested who are correctly classified
Having disease/ all positive tests
Not having disease/ all negative tests
13
Truepositive
Truenegative
Falsepositive
Falsenegative
PPV = True positives
All positives
a + c b + d
= a
a + b
NPV = True negatives All negatives
= dc + d
a + b
c + d
True Disease Status
Cases Non-cases
Positive
Negative
ScreeningTest
Results
a d b
c
X 100
X 100
True Disease Status
Cases Non-cases
Positive
Negative
ScreeningTest
Results
a d
1,000 b
c60
PPV =True positives
All positives
200 20,000
= 1401,140
NPV = True negatives All negatives
= 19,00019,060
1,140
19,060
140
19,000
=
= 12.3%
99.7%
15
Positive predictive value, Sensitivity, specificity, and prevalence
Se (%) Sp (%) Prevalence (%) PV+ (%) 0.1 1.47095
1.0 12.37095
5.0 42.47095
50.0 93.37095
Cut off point: the point at which a test results is considered to change from +v to –v. so by moving the cut off point will change every parameter in the test.
Lower cut-point:increases sensitivity, reduces specificity
Higher cut-point:reduces sensitivity, increases specificity
17
Considerations in selection of cut-point
Implications of false positive results
• burden on follow-up services
• labelling effect
Implications of false negative results
• Failure to intervene
Ethics in screening
• Informed consent obtained?
• Implications of positive result?
• Number and implications of false positives?
• Labeling and stigmatization