Clinical Effectiveness: Interpreting test results Nick Price 17 th October 2006

Aims to reflect on the implications of a study of health professional's interpretation of a test result to reflect on the implications of a study of health professional's interpretation of a test result to develop skills in interpreting test results to develop skills in interpreting test results

Objectives By the end of the session you should be able to: Define sensitivity in ordinary language Define sensitivity in ordinary language Define specificity in ordinary language Define specificity in ordinary language Understand how the prevalence of a condition in your test population influences the significance of a positive test result in a particular patient. Understand how the prevalence of a condition in your test population influences the significance of a positive test result in a particular patient. Understand how 'testing more patients, just in case' will influence the likelihood of a patient with a positive result having the condition. Understand how 'testing more patients, just in case' will influence the likelihood of a patient with a positive result having the condition. Understand to term 'positive predictive value'. Understand to term 'positive predictive value'. Have an opportunity to try explaining the result of a test to your peers. Have an opportunity to try explaining the result of a test to your peers.

Sensitivity How many true positives in comparison to the gold standard. How many true positives in comparison to the gold standard. Or (most accurately) The chance of having a positive test, assuming that you do have the condition. The chance of having a positive test, assuming that you do have the condition.Or So with a very Sensitive Test a Negative will rule Out the condition – SnNOut So with a very Sensitive Test a Negative will rule Out the condition – SnNOutOr So a sensitive test is likely to pick up the condition. So a sensitive test is likely to pick up the condition.

Sensitivity 2 Can you think of some tests with very high sensitivity in comparison to a gold standard? e.g. D-dimer (99%), Leucocytes on Multistix (87%), random blood sugar

Specificity (most accurately) The chance of having a negative test given that you do not have the disease. The chance of having a negative test given that you do not have the disease.Or How many false negatives. How many false negatives.Or With a very Specific test a Positive result rules the condition IN -SpPin So with a specific test a positive test is likely to mean you have the condition. So with a specific test a positive test is likely to mean you have the condition.

Specificity 2 Can you think of some very specific tests? 3+ of glucose and ketones on multistix? A hard craggy breast lump? A yes score of 3+ on CAGE (99.8%) Some not very specific ones: Moderately raised random blood sugar in general population

The Truth Table TRUTH POSITIVENEGATIVE TESTTEST POSITIVE ab NEGATIVE cd Sensitivity is the probability [a / (a + c) in the table] that a true positive has been correctly classified as positive by the test. Specificity is the probability [d / (b + d)] that a true negative is correctly classified negative by the test

Example With leukocyte esterase dipstix (LED) for chlamydia vs gold standard In a GUM clinic 500 patients were tested, 100 tested positive with gold standard, 90 tested positive with LED. Of these 90, 5 were in fact negative with the gold standard. What is the sensitivity and specificity of LED

Example 2 Sensitivity = 85/100 = 85% Specificity = 395/400 = 98% Truth Truth Test+-Total Total

So what is the chance that a positive LED test means you have chalmydia? Aka what is the positive predictive value (PPV). Aka what is the positive predictive value (PPV). This is the true positives / true positives and the false positives This is the true positives / true positives and the false positives PPV = a/a+c = 85/90 = 94%. PPV = a/a+c = 85/90 = 94%. Excellent, so this is a good test to use in GP e.g. routinely when taking smears!

PPV 1 So the incidence of chlamydia in the general population of all women having smears in GP is say 5%. We do 500 smears a year We have a test that has sensitivity of 85% and a marvellous specificity of 98%. What chance the patient with a positive test actually has chlamydia in this context?

Example 3 Sensitivity = 85% Specificity = 98% PPV = 21/31 = 67% NPV = 465/469 = 99% Truth Truth Test+-Total Total 500x5% =

So the incidence of the disease greatly effects the PPV or how many patients you will see with false positive test result

So what about the case in the experimental study? 1% of babies have Downs 1% of babies have Downs If the baby has Downs 90% will have +ve test. If the baby has Downs 90% will have +ve test. If the baby does not have Downs 1% chance the result will be positive If the baby does not have Downs 1% chance the result will be positive With a +ve result what is the chance baby has Downs? With a +ve result what is the chance baby has Downs?

So what about the case in the experimental study? 2 1% of babies have Downs (incidence) 1% of babies have Downs (incidence) If the baby has Downs 90% will have +ve test. (90% sensitivity) If the baby has Downs 90% will have +ve test. (90% sensitivity) If the baby does not have Downs 1% chance the result will be positive (99% specificity) If the baby does not have Downs 1% chance the result will be positive (99% specificity) With a +ve result what is the chance baby has Downs? (PPV) With a +ve result what is the chance baby has Downs? (PPV)

Example 4 – Maths solution Sensitivity = 90% Specificity = 99% PPV = 90/190 = 47% NPV = 9800/9810 = 99.9% Truth Truth Test+-Total Total

Example 4 – narrative solution Read the paper! Read the paper! Now practice explaining one of these example in trios, then rotate.

Objectives By the end of the session you should be able to: Define sensitivity in ordinary language Define sensitivity in ordinary language Define specificity in ordinary language Define specificity in ordinary language Understand how the prevalence of a condition in your test population influences the significance of a positive test result in a particular patient. Understand how the prevalence of a condition in your test population influences the significance of a positive test result in a particular patient. Understand how 'testing more patients, just in case' will influence the likelihood of a patient with a positive result having the condition. Understand how 'testing more patients, just in case' will influence the likelihood of a patient with a positive result having the condition. Understand to term 'positive predictive value'. Understand to term 'positive predictive value'. Have an opportunity to try explaining the result of a test to your peers. Have an opportunity to try explaining the result of a test to your peers.