Association & Causation Manish Chaudhary BPH(IOM, TU) MPH(BPKIHS) [email protected].
Screening [email protected] Manish Chaudhary BPH(IOM), MPH(BPKIHS)
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Transcript of Screening [email protected] Manish Chaudhary BPH(IOM), MPH(BPKIHS)
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Screening
• The process, by which unrecognized disease or defects are identified by test that can be applied rapidly on a large scale is known as screening.
• Screening sorts out healthy people from those whom may have a disease.
• It is not diagnostic.
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Screening
• The early detection of–disease–precursors of disease–susceptibility to disease
in individuals who do not show any signs of disease
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Screening
• It is preventive function
• Detection of hidden disease or condition
• It differ from periodic health examination
• A screening test is not intended to be a diagnostic test
• Should be capable of wide application
• Inexpensive
• Can be used by health workers
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Screening
• Concept lead time
• Onset S point Diagnosis Usual Dx Outcome
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Diagnosis = Screening Screening tests can also often be used as
diagnostic tests Diagnosis involves confirmation of presence or
absence of disease in someone suspected of or at risk for disease
Screening is generally in done among individuals who are not suspected of having disease
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Screening
• There is different between screening and diagnostic test:
• Health VS sick
• Group VS individual
• Result final VS require further test
• Criteria and cut off point VS overall evaluation
• Less accurate VS more accurate
• Not the basis for treatment
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Screening and Diagnostic Tests Contrasted
Screening test Diagnostic test
1. Done on apparently healthy Done on those with indication or sick
2. Applied to groups (single disease considered)
Applied to single patient (All diseases are considered)
3. Test results are arbitrary and final Diagnosis not final, is the sum of all evidence
4. Based on one criterion or cut-off point (e.g. diabetes)
Number of symptoms, signs and laboratory findings.
5. Less accurate More accurate
6. Less expensive More expensive
7. Not a basis for treatment Used as a basis for treatment
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Susceptible Host
Subclinical Disease
Clinical Disease
Stage of Recovery, Disability, or Death
Point of Exposure
Screening
Onset of symptoms
Diagnosis sought
Natural History of Disease
Detectable subclinical disease
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Screening Process
TestNegative
Re-screen
Unaffected
Intervene
Affected
TestPositive
Population(or target group)
Screening
ClinicalExam
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Population
Test -ve Test +ve
Re-screen
UnaffectedAffected
Re-Screen Screen Intervention
Screening test
Diagnostic procedure
Concept of Screening Process
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Examples of Screening Tests
• Questions• Clinical Examinations• Laboratory Tests• Genetic Tests• X-rays
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Aspect Requirement
Disorder Well defined
Prevalence Known
Natural history Medical important disorder for which there is an effective remedy available
Financial Cost-effective
Facilities Available or easily installed
Ethical Produce following a positive result generally agreed and acceptable
Test Simple and safe
Test performance Values in affected and unaffected individuals known, overlapping sufficiently small, and suitable cut off values defined
Basic Features of Screening Program
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Uses of Screening a) Case Detection: This is also known as “ prescriptive
screening. It is defined as the presumptive identification of unrecognized disease, which does not arise from a patient’s request, e.g. neonatal screening. People are screened primarily for their own benefit.
b) Control of Disease: This is also known as prospective screening. People are examined for the benefit of other, e.g. screening of immigrants from infectious disease such as TB and Syphilis to protect the home population.
The screening program may, by leading to early diagnosis permit more effective treatment and reduce the spread of infectious disease and/or mortality from the disease.
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c) Research Purpose: There are many chronic diseases whose natural history is not fully known ( e.g., cancer, hypertension). Screening may aid in obtaining more basic knowledge about the natural history of such diseases.
d) Educational opportunities: Screening program provide opportunities for creating public awareness and educating health professionals.
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Types of screening• Mass screening:
Mass screening means screening of whole population or sub population as for example all adults. It is offered to all , irrespective of the particular risk individual may run of contracting the disease in question( e.g. tuberculosis)
• High risk or selective screening
Screening will be productive if applied selectively to high risk groups , the groups defined on the basis of epidemiological research. For example , since cancer cervix tends to occur relatively less in upper social groups, screening for cancer cervix in lower social class would increase new cases.
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• Multiphasic screening
It has been defined as the application of two or more screening tests in combination to a large number of people at one time than to carry out separate screening tests for single disease.
• Case finding or opportunistic screening
It is restricted to patients who consult a health practioner for some other purposes.
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Criteria of Screening Programme
The criteria for the screening Programme are based on two considerations:
• Disease to be screened and • Tests to be applied.
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The Disease Criteria• The condition sought should be an
important health problem.• There should be a recognizable latent or
early asymptomatic stage• The natural history of the disease should be
clearly understood• There should be a test that can detect the
disease prior to the onset of sign and symptoms.
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The Disease Criteria• Facilities should be available for the
confirmation of diagnosis• There should be an effective treatment.• There should be good evidence that early
detection and treatment reduces morbidity and mortality.
• The expected benefit of early detection exceeds the risks and costs.
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Criteria of the Screening Test:The test must satisfy the criteria of• acceptability, • repeatability and • validity, • simplicity, • safety, • rapidity, • ease of administration and cost.
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Validity (Accuracy)
• The term validity refers to what extent the test accurately measures which it purports to measure.
• Validity express the ability of a test to separate or distinguish those who have the disease from those who do not.
• For example Glycosuria is a useful screening test for diabetes, but a more valid or accurate test is the glucose tolerance test.
• Accuracy refers to the closeness with which measured values agree with “ true” values.
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Two Components of Validity
Sensitivity and Specificity• Both these components should be
considered when assessing the accuracy of the diagnostic test.
• Expressed in percentage • Both are usually determined by
applying the test to one group of persons having the disease, and to a reference group not having the disease.
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Screening Test Results by Diagnosis
Screening test results Diagnosis Total
Diseased Not diseased
Positive a (True positive) b (False positive) a+b
Negative c (False negative) d (True negative) c+d
Total a+c b+d a+b+c+d
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“a” denotes those individuals found positive on the test who have the condition or disorder being studied (i.e., true positives).
“b” includes those who have the positive test result but who do not have the disease (i.e., false positives).
“c” includes those with negative test result who have the disease (i.e., false negative)Finally, those with negative results who do not have the disease are included in group “d” (i.e. true negatives).
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The following measures are used to evaluate a screening test:
• Sensitivity = a/(a+c) x 100• Specificity = d/(b+d) x 100• Predictive Value of a positive test = a/(a+b) x 100• Predictive Value of a negative test = d/(c+d) x 100• Percentage of false negatives = c/(a+c) x 100• Percentage of false Positives = b/(b+d) x 100
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Sensitivity
• It is a statistical index of diagnostic accuracy.
• Defined as the ability of a test to identify correctly all those who have the disease, i.e., true positive.
• A 90 percent sensitivity means that 90 percent of the diseased people screened by the test will give a “true positive” result and the remaining 10 percent a “false negative” result.
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Specificity
• It is defined as the ability of a test to identify correctly those who do not have the disease, i.e., “ true negatives”.
• 90 % specificity means that 90 percent of the non-diseased persons will give “true negative” result, 10 % pf the non-diseased persons screened by the test will be wrongly classified as “diseased” when they are not
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False negative
• The term false negative means that patients who actually have the disease are told that they do not have the disease.
• It amounts to giving them false reassurance.• A screening test which is very sensitive has
few false negative.• Lower the sensitivity, larger will be the
number of false negatives.
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False Positive
• The term false positive means that patients who do not have the disease are told that they have.
• A screening test with a high spcificity will have few false positives.
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Positive Predictive value
• proportion of disease individuals among those with positive test results or probability of the person having the disease when the test is positive
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Negative predictive value
• proportion of individuals without disease among those negative test results or probability of the person not having the disease when the test is negative
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Yield
Yield is the amount of previously unrecognized disease that is diagnosed as a result f the screening effort.
It depends upon the many factors such as sensitivity and specificity of the test, prevalence of disease, participants of individuals in the detection program.
High risk population are usually selected for screening, thus increasing the yield.
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Screening Test Results by Diagnosis
Screening test results Diagnosis Total
Diseased Not diseased Positive a (True positive)
40b (False positive) 20
a+b60
Negative c (False negative) 100
d (True negative) 9840
c+d9940
Total a+c 140
b+d 9860
a+b+c+d10,000
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Evaluation of screening test
a) Sensitivity (true positive)= 40/140 x 100 = 28.57%
b) Specificity (true negative) = 9840/9860 x 100 = 99.79%
c) False negative = 100/140 x 100 = 71.4 %
d) False positive = 20/9860 x 100 = 0.20 %
e) Predictive value of positive test = 40/60 x 100 = 66.67%
f) Predictive value of negative test
= 9840/9940 x 100 = 98.9%
The more prevalent a disease the more accurate will be the predictive value of a positive screening test .
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The best diagnostic tests are those that yield few false positives and few false negatives: high sensitive and
high specific
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Uses of sensitive test
1. A sensitive test should be choosen when there is an important penalty for missing a disease. The diseases which are dangerous but treatable e.g. tuberculosis, syphilis, breast cancer etc.
2. Proportion of false positive is tolerable but not false negative
Uses of specific test
1. It is useful to confirm the diagnosis that has been suggested by other data.
2. Highly specific tests are particularly needed when false positive results can harm patient physically, emotionally, or financially.
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Trade off between sensitivity and specificity
• One characteristic (e.g. sensitivity) can only be increased at the expense of the other (e.g. specificity).
• Simply, we can get the sum of sensitivity and specificity of each test and that test which has highest sum is selected for the diagnosis.
• A figure plotting the true
positive rate (sensitivity) against the false positive rate is called the receiver operator characteristics of the test (ROC curve).
Sen
siti
vit
y (
%)
Tru
e p
osi
tiv
e ra
te
1 - s p ec if ic ity ( % )F als e p o s it iv e r a tes
2 0 4 0 6 0 8 0 1 0 0
2 0
4 0
6 0
8 0
1 0 0
Figure: ROC curve
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Criteria for Assessing the Screening Test
Simplicity- a test should be simple to perform, and easy to interpret
Acceptability- since participation in screening is voluntary, a test should be acceptable to those undergoing it.
Accuracy- a test must give true measurement of the condition or symptom under investigation
Cost- the expense of test must be considered in relation to the benefits of detection of disease
Precision or repeatability- the tests should give consistent results in repeated examinations
Sensitivity- a test should be capable of giving positive findings when the person being screened has the disease being sought
Specificity- a test should be capable of giving negative findings when a person being screened does not have the disease being sought.
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Reliability of screening test
• It is also known as repeatability. • Factors contribute to the variation between test
are: – Intra subject variation
• Many human characteristics vary because of the change in time of day even during a short period of time, and because of conditions under which certain tests are conducted (e.g. pp glucose )
– Inter-observer variation: variation between observers
– Overall percent agreement (OPA) = (a+d)/(a+b+c+d) x 100
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Criteria for Instituting a Screening Program
Disease • Serious • High prevalence of preclinical stage • Natural history understood • Long period between first signs and overt disease
Diagnostic tests• Sensitive and specific• Simple and cheap • Safe and acceptable • Reliable
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Evaluation of Screening Programme
• Evaluation of screening test can be performed by– Randomized controlled trials– Uncontrolled trials ( cervical cancer screening )– Other methods ( case control and comparison
studies0
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Thank You