1. www.cebm.net Evidence Based Health Care Course Paris, 2010 Appraising diagnostic studies Dr Matthew Thompson Senior Clinical Scientist

2. www.cebm.net What is diagnosis? Increase certainty about presence/absence of disease Disease severity Monitor clinical course Assess prognosis – risk/stage Plan treatment e.g., location Stall for time!

3. www.cebm.net 2/3 malpractice claims against GPs in UK 40,000-80,000 US hospital deaths from misdiagnosis per year Adverse events, negligence cases, serious disability more likely to be related to misdiagnosis than drug errors Diagnosis uses <5% of hospital costs, but influences 60% of decision making

4. www.cebm.net Series of patients Index test Reference (gold) standard Compare the results of the index test with the reference standard, blinded Basic structure of diagnostic studies

5. www.cebm.net Appraising diagnostic tests: 3 easy steps 1. Are the results valid? 2. What are the results? 3. Will they help me look after my patients? Appropriate spectrum of patients? Does everyone get the gold standard? Is there an independent, blind or objective comparison with the gold standard? Sensitivity, specificity Likelihood ratios Predictive values Can I do the test in my setting? Do results apply to the mix of patients I see? Will the result change my management? Costs to patient/health service?

6. www.cebm.net Appropriate spectrum of patients? Ideally, test should be performed on group of patients in whom it will be applied in the real world clinical setting Spectrum bias = study uses only highly selected patients…….perhaps those in whom you would really suspect have the diagnosis

7. www.cebm.net All patients have the gold standard? Ideally all patients get the gold /reference standard test Work-up bias = only some patients get the gold standard…..perhaps the ones in whom you really suspect have the disease

8. www.cebm.net Ideally, the gold standard is independent, blind and objective Observer bias = test is very subjective, or done by person who knows something about the patient Independent, blind or objective comparison with the gold standard?

9. 2 by 2 table Disease Test +- + - True positives False negatives True negatives False positives

10. 2 by 2 table: sensitivity Disease Test +- + - Sensitivity = a / a + c Proportion of people with the disease who have a positive test result. a True positives c False negatives

11. 2 by 2 table: specificity Disease Test +- + - b False positives d True negatives Specificity = d / b + d Proportion of people without the disease who have a negative test result.

12. 2 x 2 table: positive predictive value Disease Test +- + - c ab d PPV = a / a + b Proportion of people with a positive test who have the disease

13. 2 x 2 table: negative predictive value Disease Test +- + - c ab d NPV = d / c + d Proportion of people with a negative test who do not have the disease

14. Likelihood ratios Positive likelihood ratio (LR+) How much more likely is a positive test to be found in a person with the disease than in a person without it? LR+ = sens/(1-spec) Negative likelihood ratio (LR-) How much more likely is a negative test to be found in a person without the condition than in a person with it? LR- = (1-sens)/(spec)

15. 2 x 2 table: positive likelihood ratio Disease Test +- + - c ab d LR+ = a/a+c / b/b+d or LR+ = sens/(1-spec) How much more often a positive test occurs in people with compared to those without the disease

16. 2 x 2 table: negative likelihood ratio Disease Test +- + - c ab d LR - = c/a+c / d/b+d or LR - = (1-sens)/(spec) How less likely a negative test result is in people with the disease compared to those without the disease

17. What do likelihood ratios mean? LR>10 = strong positive test result LR<0.1 = strong negative test result LR=1 No diagnostic value

18. Will the test apply in my setting? Reproducibility of the test and interpretation in my setting Do results apply to the mix of patients I see? Will the results change my management? Impact on outcomes that are important to patients? Where does the test fit into the diagnostic strategy? Costs to patient/health service?

19. Refinement of the diagnostic causes Restricted Rule Outs Stepwise refinement Probabilistic reasoning Pattern recognition fit Clinical Prediction Rule Spot diagnoses Self-labelling Presenting complaint Pattern recognition Initiation of the diagnosis Defining the final diagnosis Known Diagnosis Further tests ordered Test of treatment Test of time No label How do clinicians make diagnoses? Diagnostic stages & strategies (Heneghan et al, BMJ 2009) Stage Strategies used

20. Evaluating the roles of new tests Replacement – new replaces old E.g., CT colonography for barium enema Triage – new determines need for old E.g., B-natriuretic peptide for echocardiography Add-on – new combined with old ECG and myocardial perfusion scan Bossuyt et al BMJ 2006;332:1089–92

21. Stepwise evaluation of new diagnostic tests. Van den Bruel A, J Clin Epidemiol 2007. Bossuyt P, BMJ 2006

22. www.cebm.net Whats next? In your small groups, pick a diagnostic article Rapidly appraise it using the 3 steps Explain sensitivity/specificity etc THANK YOU!