Information Mastery:A Practical Approach to Evidence-Based Care

Course Directors:Allen Shaughnessy, PharmD, MMedEd

David Slawson, MD

Tufts Health Care InstituteTufts University School of Medicine

November 10-12, 2011Boston, Massachusetts

Information Mastery:A Practical Approach to Evidence-Based Care

Is It True? Evaluating Research about Diagnostic Tests

The Case of Baby Jeff

CPK testing for Muscular Dystrophy• Sensitivity: 100%

• Specificity: 99.98%

Prevalence: 1 in 5,000 (0.02%)

Sensitivity 100%

99,980 – no M.D.20 will have M.D.

20 correctly positive

0 false negative

20 false positive

99,960 correctly negative

99,960 negative tests

100% truly negative

0 falsely negative

100% NPV

40 positive tests

50% truly positive

50% falsely positive

50% PPV

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Prevalence = 1 in 5,000 = .02% = 20 newborn boys

100,000 newborn boys

Specificity 99.98%

Why this is important

http://today.msnbc.msn.com/id/42829175

Other examples

Lyme disease• Sensitivity= 95%; specificity= 95%

• High prevalence (20%): PPV =83%

• Low prevalence (2%): PPV = 28% Echocardiogram as part of executive physical

• Prevalence = 10%; PPV = 50%

Technical vs. Clinical Precision

Technical precision Clinical precision

SensitivityThe percentage of patients with the disease who have a positive test

Positive predictive valueThe percentage of patients with a positive test who have the disease

SpecificityThe percentage of patients without disease who test negative

Negative predictive valueThe percentage of patients with a negative test who are without disease.

Predictive Values

Positive Predictive Value• The percentage of patients with a positive test who

have the disease Negative Predictive Value

• The percentage of patients with a negative test who don’t have the disease

Let’s practice

Task 1. A serum test screens pregnant women for babies with Down’s syndrome. The test is a very good one, but not perfect. Roughly, 1% of babies have Down’s syndrome. If the baby has Down’s syndrome, there is a 90% chance that the result will be positive. If the baby is unaffected, there is still a 1% chance that the result will be positive. A pregnant woman has been tested and the result is positive.

Positive: 90% correctly identified

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Prevalence = 1% = ___ patients/1,000?

1,000 similar

Negative: 99% correctly identified

Positive: 90% correctly identified

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Prevalence = 1% = ___ patients/1,000?

1,000 similar

Negative: 99% correctly identified

Positive: 90%correctly identified

990 No Downs10 – Downs

1 false negative

10 false positive

980 correctly negative

981 negative tests

99.99% truly negative

0.001% falsely negative

19 positive tests

47.5% truly positive

52.5 falsely positive

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Prevalence = 1% = 10 with Downs

1,000 similar patients

Negative: 99%correctly identified

Down’s Syndrome

9 correctly positive

Task 2

A 45-year-old woman presents with a sore throat and cough but without fever, tonsillar exudate, or cervical nodes. Using a clinical decision rule, you determine her likelihood of having strep throat is 1%. However, according to your office protocol, your medical assistant already has performed a rapid strep (antigen) test, which is positive. What is the likelihood the patient has strep throat now?

Antigen test -- Sensitivity: 88% Specific: 96%

Sensitivity 88%

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Prevalence = 1% = 1,000 with strep

100,000 similar patients

Specificity 96%

Strep throat

Sensitivity 88%

99,000 – viral1,000 – Strep

880 correctly positive

120 false negative

3,960 false positive

95,040 correctly negative

95,160 negative tests

99.87% truly negative

0.126% falsely negative

99.87% NPV

4840 positive tests

18% truly positive

82% falsely positive

18% PPV

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Prevalence = 1% = 1,000 with strep

100,000 similar patients

Specificity 96%

Strep throat

Adopting new screening/diagnostic tests

Sensitivity/specificity not enough Testing as an intervention

• Did the authors study an outcome patients care about?

Levels of “POEMness” for Diagnostic Tests

1. Sensitivity & specificity2. Does it change diagnoses?3. Does it change treatment?4. Does it change outcomes?5. Is it worthwhile (to patients and/or society)?

(examples: HbA1C for DM, CPK vs T4/PKU in newborns, electron beam tomography for CAD)

Fryback DG, Thornbury JR. The efficacy of diagnostic imaging. Med Decis Making 1991; 11:88-94

Screening pulse oximetry for CHD Diagnostic performance of abnormal pulse oximetry for congenital heart

defects

for all major congenital defects         *  sensitivity 49.06%          *  specificity 99.016%          *  positive predictive value 13.33%          *  negative predictive value 99.86%     

for critical congenital defects          *  sensitivity 75%          *  specificity 99.12%          *  positive predictive value 9.23%          *  negative predictive value 99.97%

Lancet 2011 Aug 27;378(9793):785

Screening pulse oximetry for CHD

Jaundice, terminating breast-feeding, and the vulnerable child      Breast-feeding was more common in the jaundiced group (61% vs

79%). By 1 month, more mothers of jaundiced infants had completely stopped breast-feeding (19% vs 42%). They were more likely to have never left the baby with anyone else (including the father) or left the baby at most one time for less than 1 hour (15% vs 31%), more well-visits, more ED visits (2% v 11%, not including bili measurements).

Thus, may increase the risk for premature termination of breast-feeding and for development of the VULNERABLE CHILD SYNDROME.

Pediatrics 1989 Nov;84(5):773-8

Naming is not curing

In the 1600s, astrology dominated medicine as a healing profession. Neither worked but astrology was much more popular because it focused on fixing people's problems. Medicine, on the other hand, focused mainly on categorizing illnesses (i.e., diagnosing) and not so much on treatment.

400 years later there is still a priority on categorizing, regardless of whether it's helpful. A correct diagnosis is only useful when it results in the selection of a treatment that benefits the patient; otherwise, it's only a label.

James Burke. The day the Universe Changed. Boston: Little, Brown and Company, 1985, p. 333.

Clinical Decision Rules

Essential Evidence Plus

ATPIII Pap Smear and Trich Ottawa Ankle & Knee

Rules