EBM diagnostic

Kanti Ratnaningrum
Skenario Klinis
• Seorang anak laki-laki umur 10 tahun datang ke
dokter dengan keluhan sakit tenggorokan. Sakit
tenggorokan dirasakan sudah lima hari. Sebagian
besar penyebab faringitis adalah virus. Yang
menjadi fokus perhatian dokter adalah
mendiagnosis pasien apakah faringitis ini
disebabkan oleh streptokokus Grup A (GAS). Hal
ini membutuhkan pemeriksaan kultur bakteri tapi
memerlukan waktu lebih dari satu hari, untuk
mempercepat diagnosis, dokter
mempertimbangkan penggunaan pemeriksaan
lain.
• Pemeriksaankultur merupakan “gold standrat”
untuk mendiagnosis faringitis oleh karena GAS.
Waktu yang diperlukan untuk pemeriksaan kultur
ini sekitar 24-48 jam.
• A quantitative polymerase chain reaction (qPCR)
adalah teknik laboratorium biologi molekuler
berdasarkan reaksi berantai polimerase ( PCR )
yang dapat sedang dikembangkan.
• Sebelum dokter mempertimbangkan perubahan
alur diagnosis pasien faringitis, sensitifitas qPCR
dibandingkan dengan pemeriksaan kultur untuk
mendeteksi GAS
 Steps in Practicing EBM
1. Convert the need for information into an
answerable question.
2. Track down the best evidence with which to
answer that question.
3. Critically appraise the evidence for its validity,
impact, and applicability.
4. Integrate the evidence with our clinical
expertise and our patient’s characteristics and
values.
5. Evaluating our effectiveness and efficiency in
executing steps 1–4 and seeking ways to
improve them both for next time.
 The clinical question: PICO

Patient or Intervention Comparison Outcome

Problem
Anak dengan A quantitative Gold Diagnosis of
suspek Group polymerase standard: faringitis e.c
A chain reaction kultur GAS
streptococcus (qPCR)
(GAS)
 Pertanyaan klinis
• Pada pasien anak dengan suspek GAS yang
dilakukan pemeriksaan qPCR dapat seakurat
pemeriksaan kultur dalam membantu
diagnosis?
 Steps in Practicing EBM
1. Convert the need for information into an
answerable question.
2. Track down the best evidence with which to
answer that question.
3. Critically appraise the evidence for its validity,
impact, and applicability.
4. Integrate the evidence with our clinical
expertise and our patient’s characteristics and
values.
5. Evaluating our effectiveness and efficiency in
executing steps 1–4 and seeking ways to
improve them both for next time.
 The search strategy
• Pubmed database:
(http://www.ncbi.nlm.nih.gov/sites/entrez?db=
pubmed)
• Using the Clinical Queries function of PubMed:
– Key words:
• “GAS” AND
• “qPCR”
– Clinical Study Categories: “Diagnosis”
– Scope: “Narrow”
 The Evidence
• Detection of group a streptococcal pharyngitis by
quantitative PCR

• Dunne EM, Marshall JL, Baker CA, Manning J,

Gonis G, Danchin MH, Smeesters PH, Satzke C,
Steer AC. 2013. Detection of group a
streptococcal pharyngitis by quantitative PCR.
BMC Infectious Diseases 2013, 13:312
http://www.biomedcentral.com/1471-
2334/13/312
 Steps in Practicing EBM
1. Convert the need for information into an
answerable question.
2. Track down the best evidence with which to
answer that question.
3. Critically appraise the evidence for its
validity, impact, and applicability.
4. Integrate the evidence with our clinical
expertise and our patient’s characteristics and
values.
5. Evaluating our effectiveness and efficiency in
executing steps 1–4 and seeking ways to
improve them both for next time.
 Appraising the Evidence
1. Is this evidence about the accuracy of a
diagnostic test valid?
2. Does this (valid) evidence demonstrate an
important ability of this test to accurately
distinguish patients who do and do not have
a specific disorder?
3. Can I apply this valid, important diagnostic
test to a specific patient?
Is this evidence about the accuracy of a diagnostic test
valid?
1. Measurement
– Was the reference (“gold”) standard measured independently?
Ya (halm 2 dari 7)
Is this evidence about the accuracy of a diagnostic test
valid?
2. Representative
– Was the diagnostic test evaluated in an appropriate spectrum of
patients (those in whom we would use it in practice)?
Ya
Is this evidence about the accuracy of a diagnostic test
valid?
3. Ascertainment
– Was the reference standard ascertained regardless of the diagnostic
test result?
Ya
 Are the results of this study valid?

• Ya
 Appraising the Evidence
1. Is this evidence about the accuracy of a
diagnostic test valid?
2. Does this (valid) evidence demonstrate an
important ability of this test to accurately
distinguish patients who do and do not have
a specific disorder?
3. Can I apply this valid, important diagnostic
test to a specific patient?
 Tabel 2x2

speB
• Sensitifitas: 24/(24+0). 100= 100%  benar-benar (+) GAS
• Spesifisitas: 103/(0+103).100= 100%  benar-benar (-) GAS
• PPV: 24/(24+0). 100= 100%
 100% dari pasien yang dinyatakan (+) adalah benar disebabkan GAS
• NPV: 103/(0+103).100= 100%
 100% dari pasien yang dinyatakan (-) benar-benar tidak disebabkan oleh GAS
 Tabel 2x2

spy1258
• Sensitifitas: 21/(21+3). 100= 87%  benar-benar (+) GAS
• Spesifisitas: 103/(0+103).100= 100%  benar-benar (-) GAS
• PPV: 21/(21+0). 100= 100%
 100% dari pasien yang dinyatakan (+) adalah benar disebabkan GAS
• NPV: 103/(3+103).100= 97%
 97% dari pasien yang dinyatakan (-) benar-benar tidak disebabkan oleh GAS
• Sensitifitas 100%
• spesifisitas 100%

• Prevalensi carier faringitis GAS  12%

(Shaikh N et al. 2010)
 Appraising the Evidence
1. Is this evidence about the accuracy of a
diagnostic test valid?
2. Does this (valid) evidence demonstrate an
important ability of this test to accurately
distinguish patients who do and do not have
a specific disorder?
3. Can I apply this valid, important diagnostic
test to a specific patient?
 Are the results of this diagnostic study
applicable to my patient?

1. Is the diagnostic test available, affordable,

accurate, and precise in our setting?
• Ya, akurat dan tersedia (tetapi tidak di semua
laboratorium)
• Tetapi tidak terjangkau untuk semua pasien
(hanya keluarga kalangan menengah ke atas)
• Dan belum tepat dilakukan karena berbagai
pertimbangan
 Are the results of this diagnostic study
applicable to my patient?

2. Can we generate a clinically sensible estimate of

our patient’s pre-test probability?
a. From personal experience, prevalence statistics, practice
databases, or primary studies.
• Ya
b. Are the study patients similar to our own?
• Ya
c. Is it unlikely that the disease possibilities have changed
since this evidence was gathered?
• Ya
 Likelihood Ratio

SpeB
• Likelihood Ratio+ = sens/(1-spec) = 100/(100-100) = ~
• Likelihood Ratio- = (1-sens)/spec = (100-100)/100 = 0
• Prevalence = (a+c)/(a+b+c+d) = 24/127 = 18.9%
• Study pre-test odds = prevalence/(1-prevalence) = 18.9/81.1 = 23.3
• Post-test odds = pre-test odds x likelihood ratio = 23.3 x ~ = ~
• Post-test probability = post-test odds/(post-test odds +1) = ~ / ~ = ~
 Likelihood Ratio

Spy1258
• Likelihood Ratio+ = sens/(1-spec) = 87/(100-100) = ~
• Likelihood Ratio- = (1-sens)/spec = (100-87)/100 = 13
• Prevalence = (a+c)/(a+b+c+d) = 24/127 = 18.9%
• Study pre-test odds = prevalence/(1-prevalence) = 18.9/81.1 = 23.3
• Post-test odds = pre-test odds x likelihood ratio = 23.3 x ~ = ~
• Post-test probability = post-test odds/(post-test odds +1) = ~ / ~ = ~
 Are the results of this diagnostic study
applicable to my patient?

3. Will the resulting post-test probabilities

affect our management and help our
patient?
1. Could it move us across a test-treatment
threshold?
• Ya, dari pre-test probability of 18.9% ke post-test
probability of ~
 Are the results of this diagnostic study
applicable to my patient?
3. Will the resulting post-test probabilities affect our
management and help our patient? (cont.)
2. Would our patient be a willing partner in carrying it out?
• Mungkin iya
3. Would the consequences of the test help our patient
reach his or her goals in all this?
• Ya, jika hasil (-), jika hasil (+) dapat membantu dalam hal
pengobatan dan pencegahan komplikasi seperti DRA dll
 Steps in Practicing EBM

1. Convert the need for information into an

answerable question.
2. Track down the best evidence with which to
answer that question.
3. Critically appraise the evidence for its validity,
impact, and applicability.
4. Integrate the evidence with our clinical
expertise and our patient’s characteristics
and values.
5. Evaluating our effectiveness and efficiency in
executing steps 1–4 and seeking ways to
improve them both for next time.
How can I apply the results to patient
care?
• Tes qPCR speB ini sangat bagus karena memiliki
sensitifitas dan spesifitas tinggi, sehingga dapat
digunakan untuk meningkatkan ketepatan
diagnosis dan dan terapi serta mencegah
komplikasi
• Tes qPCR mungkin tidak efektif dari segi
pembiayaan dan keterjangkauan karena tidak
semua laboratorium memiliki fasilitas PCR ini
• berbagai faktor harus dipertimbangkan sebelum
penggunaan tes qPCR dalam strategi diagnosis,
terapi dan pencegahan komplikasi
 Steps in Practicing EBM
1. Convert the need for information into an
answerable question.
2. Track down the best evidence with which to
answer that question.
3. Critically appraise the evidence for its validity,
impact, and applicability.
4. Integrate the evidence with our clinical
expertise and our patient’s characteristics and
values.
5. Evaluating our effectiveness and efficiency
in executing steps 1–4 and seeking ways to
improve them both for next time.
Terimakasih