Diagnosis

Research Methods Dent 313

Diagnosis
This lecture deals with the basic principles to follow when interpreting diagnostic tests A diagnostic test is conventionally performed in a lab It can be performed chairside (pulp vitality testing)
It can also be obtained from history taking, physical examination and imaging procedures
E.g: Severe spontaneous pain + provoked by cold + badly decayed tooth:
All serve as a diagnostic test to irreversible pulpitis
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Simplifying data
Clinicians generally reduce the data to a simpler form in order to make it useful in practice
E.g., ordinal scales (tooth mobility) E.g., dichotomous scale (tooth present/absent, normal/abnormal)

They often change interval scale to ordinal or nominal one

E.g., blood pressurepresent/absent 90 Heart murmur to ordinal scale from I-IV

Gold standard
Is the sound assessment of the truth It is the certainty that the disease is truly present or absent Establishing the diagnosis is imperfect

Gold standard types of tests

Simple vs. elaborate Simple tests are
Easier to perform Inexpensive But,,, less accurate

Elaborate tests are

More expensive More accurate But,,, more risky
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Examples of simple and elaborate tests

Pulp vitality testing (simple) Throat culture for strep throat (simple) Histopathology for lesions (elaborate) Radiological contrast material (elaborate) Autopsies

Gold standard
However, advanced tests are not the tests of options most of the time
More costly, less feasible and more risky Simpler tests can give adequate results without a risk (at least initially)
Compromising accuracy is justified by minimizing the risk

Examples
It is easier to diagnose pneumonia with chest x-ray and sputum smear rather than lung biopsy ECG and Serum Enzyme rather than heart biopsy, catheterization or imaging as in case of MI

Gold standard
It is easier to establish diagnosis with simpler tests with understanding that there is a risk of diagnosis Therefore we are going to describe the value of diagnostic tests

Accuracy of test results

Establishing a diagnosis is a probability rather than a certainty
We commonly use possible: or rule out

Clinicians should be familiar with mathematical relationships between the properties of diagnostic tests and the information they have about them

Accuracy of test results

DISEASE
Present Absent False positive

TEST

Positive

True positive

Negative

False negative

True negative

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Sensitivity and specificity

Sensitivity
The proportion of people who tested positive for the disease from those who have the disease High sensitive test will rarely miss people with the disease

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Sensitivity and specificity

Specificity:
The proportion of people who tested negative for the disease from those without the disease High specific test will rarely miss people without the disease

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Sensitivity and specificity

Relationship between Disease sensitivity & specificity of diagnostic tests Present Absent

Test

Positive Negative

a
True positive

b
False positive

c
False negative

d
True negative

Sensitivity (Se) = a/a+c

Specificity (Sp)= d/b+d

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Prevalence (P) = a+c/a+b+c+d

Sensitivity and specificity

Example: 37 of 149 patients with sore throats were diagnosed as having pharyngitis and receive Antibiotics Only 27 of those had positive culture for streptococcus The remaining 112 with sore throats were not diagnosed as having pharyngitis and were not given Antibiotics Of the those 112, 77 had negative cultures for streptococcus
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Sensitivity and specificity

Streptococcus Cultures (Disease) Present Doctors clinical examinations (Test) Positive Negative 27 10
37

Absent 35 77
112
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62 87

Sensitivity and specificity

Streptococcus Cultures (Disease) Present Doctors clinical examinations (Test)
a b d c True +ve = 27 False +ve = 35 True ve = 77 False ve = 10

Absent 35 77
112
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Positive Negative

27 10
37

62 87

Sensitivity and specificity

A B D C True +ve = 27 False +ve = 35 True ve = 77 False ve = 10

Streptococcus Cultures (Disease) Present 27 10

37

Absent 35 77
112
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Doctors clinical examinations (Test)

Positive Negative

62 87

Sensitivity= a/a+c = 27/27+10 = 27/37 = 73% Specificity= d/b+d = 77/35+77 = 77/112=69% Prevalence= a+c/a+b+c+d = 37/149 = 25%

Use of sensitive tests

In case of important penalty of missing a condition (dangerous but treatable condition)
Tuberculosis, syphilis, Hodgkin's disease

During early stage of diagnostic workup with many possibilities to be considered in order to reduce the number of those possibilities
Fever, anemia, nausea

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Use of sensitive tests

To rule out diseases with a negative result of a highly sensitive test
Highly sensitive HIV ab test early in evaluation of lung infiltrates & wt loss to rule out AIDS-related infection

When the probability of disease is very low and the purpose of test is to discover the disease *In summary: useful when test result is negative and we dont want false negative results

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Use of specific test

Useful to confirm a diagnosis In cases when false positive results will harm the patient emotionally, physically and financially
E.g., cancer

*In summary: useful when test result is positive and we dont want false positive results
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Predictive value
Sensitivity and specificity are obtained in persons known to have or not have the disease

Predictive value of the test

Is the probability of disease, given the results of a test

Positive predictive value Is the probability of disease in a patient with a positive (abnormal) test result Negative predictive value Is the probability of not having the disease when the test result is negative (normal).
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Predictive value
If my patients test is positive, what are the chances that my patient does have the disease?
Answer: positive predictive value

If my patients test is negative, what are the chances that my patient does not have the disease?
Answer: negative predictive value

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Disease Present
Doctors Clinical Examinations (Test)

Absent b
False positive

Positive Negative

a
True positive

c
False negative

d
True negative

+ Predictive Value = a / a + b - Predictive Value = d / c + d Accuracy = a+d / a+b+c+d

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Accuracy
Accuracy summarize the overall value of a test Accuracy is the proportion of all test results, both positive and negative, that are correct Accuracy = a+d / a+b+c+d

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Streptococcus Cultures (Disease) Present Doctors clinical examinations (Test) Positive Negative 27 10 Absent 35 77
112 62 87

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+ Predictive Value = a / a + b = 27/62 = 44% -Predictive Value = d / c + d = 77/87 = 88% Accuracy = a+d/a+b+c+d = 27+77/149 =69.8%
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Sensitivity & Specificity & PV

The more sensitive a test is, the better will be its negative predictive value The more specific the test is, the better will be its positive predictive value

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Streptococcus Cultures (Disease)

Present

Absent

Doctors clinical examinations (Test)

Positive Negative

37 0

35 72 77 77

37

112

149

Sensitivity = 37/37 = 100% + P V = 37/72 = 51%

Specificity =77/112 = 69% - P V = 77/77 = 100%

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Streptococcus Cultures (Disease)

Present

Absent

Doctors clinical examinations (Test)

Positive negative

27 10

0 27 112 122

37

112

149

Sensitivity = 27/37 = 73% Specificity =112/112 = 100% + P V = 27/27 = 100% - P V = 112/122 = 92%

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Prevalence
Prev = a+c/a+b+c+d Because predictive value is also influenced by prevalence, it is not independent of the setting in which the test is used

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Prevalence
As the prevalence of disease in a population approaches zero, the positive predictive value of a test also approaches zero As prevalence approaches 100%, negative predictive value approaches zero

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Streptococcus Cultures (Disease)

Present

Absent

Doctors clinical examinations (Test)

Positive negative

27 10

35 62 77 77

37

112

149

Prevalence = 37/149 = 25% +Predictive Value = A / A + B = 27/62 = 44% - Predictive Value = D / C + D = 77/87 = 88%

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Streptococcus Cultures (Disease)

Present

Absent

Doctors clinical examinations (Test)

Positive negative

3 1

45 48 100 101

145

149

Prevalence = 4/149 = 3% +Predictive Value = A / A + B = 3/48 = 6% - Predictive Value = D / C + D = 100/145 = 69%

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Streptococcus Cultures (Disease)

Present

Absent

Doctors clinical examinations (Test)

Positive

106

1 107

negative

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2 42

146

149

Prevalence = 146/149 = 98% +Predictive Value = A / A + B = 106/107 = 99% - Predictive Value = D / C + D = 2/42 = 5%

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Estimating Prevalence
Several sources of information to estimate the prevalence
Clinical observations
Inaccurate mach wt for remarkable pts More accurate

Medical literature Local databases Clinical judgment

In general, prevalence is more important than sensitivity/specificity in determining predictive value

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Increasing the prevalence of disease

It is wise to apply diagnostic tests to those with increased probability of having the disease
Applying tests when prevalence of disease is high It is not appropriate to use vitality pulp testing in symptomatic and asymptomatic teeth

How to increase prevalence of disease Referral process

Referring patients to specialized clinics

Selected demographic groups

With higher risk for disease

Specifics of the clinical situation

When symptoms, signs, disease risk factors are present
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