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Activity 1

In a hypothetical study, 1000 patients attending a hospital general outpatient


department were tested for diabetes using the following two tests:
· fasting blood sugar (FBS)
· glucose tolerance test (GTT)

There were 100 patients who had a positive GTT, and they were classified as true cases
of diabetes. There were also 140 patients with an FBS of at least 6 mmol/l (the cut-off point
to distinguish people with diabetes from those who do not have diabetes). Among
these 140 patients, only 98 were true cases of diabetes (i.e. only 98 had a positive GTT as
well).

1. What are the sensitivity, specificity, and positive and negative predictive values of the
FBS test in this study population?
Jawab:
Tabel 2x2 of diabetes by true cases against FBS test results

Diabetes (GTT) Total


Test results (FBS)
Positive Negative

Positive 98 42 140
Negative 2 858 860
Total 100 900 1000

FBS sensitivity : 98/100 x 100 = 98%


FBS specificity : 858/900 x 100 = 95%
FBS positive predictive value : 98/140 x 100 = 70%
FBS negative predictive value : 858/860 x 100 = 99,8%

When the cut-off point for the FBS was raised to 7 mmol/l, the sensitivity of the test
decreased to 95% and the specificity increased to 98% in the hypothetical study
population.

2. Calculate the positive predictive value and false negative error rate of FBS at this cut-off
point.
Jawab:
Tabel 2x2 of diabetes by true cases against test results
Diabetes by true cases against FBS test results (cut-off 7 mmol/l)

Diabetes (GTT) Total


Test results (FBS)
Positive Negative

Positive 95 18 113
Negative 5 882 887

Theodora Ferminarti Jati. 15/388240/PKU/15462. Pascasarjana IKM Kesling. Epidemiologi Tutorial 5.


Total 100 900 1000

FBS positive predictive value: 95/113 x 100 = 84%


FBS false negative error rate: 5/100 x 100 = 5%
Alternatively,
FBS false negative error rate = 1 − sensitivity = 1 − 95% = 5%.

The FBS test and GTT were used in a hypothetical community survey to screen for
diabetes. Among 1000 people surveyed, 40 people had a positive GTT for diabetes and
were classified as true cases of diabetes. An FBS cut-off value of 6 mmol/l was used to
distinguish between people with and without diabetes; you can assume that at this cutoff
point the FBS had a sensitivity of 98% and specificity of 95%.

3. What are the positive predictive value and false negative error rate of FBS in this survey?
Jawab:
Tabel 2x2 of diabetes by true cases against test results
Diabetes by true cases against FBS test results (cut-off 6 mmol/l)

Diabetes (GTT) Total


Test results (FBS)
Positive Negative

Positive 39 48 97
Negative 1 912 913
Total 40 960 1000

FBS positive predictive value: 39/97 x 100 = 40%


FBS false negative error rate: 1/40 x 100 = 2,5%

4. Why is the positive predictive value different from that observed in the
hypothetical hospital-based study?
Jawab:
Meskipun sensitivitas dan spesifisitas dari FBS di cut- off point yang sama pada
hypothetical hospital-based study, ditandai ada penurunan nilai prediksi positif dari FBS
dalam survei komunitas. Hal ini disebabkan fakta bahwa prevalensi diabetes pada
populasi rumah sakit lebih tinggi ( 10 % ) dari komunitas ( 4 % ) .

Assume that if the cut-off point of FBS is increased to 7.5 mmol/l, the sensitivity is
90% and the specificity is 99% for diagnosing diabetes.

Theodora Ferminarti Jati. 15/388240/PKU/15462. Pascasarjana IKM Kesling. Epidemiologi Tutorial 5.


5. What are the positive predictive value and the false negative error rate of FBS if the cut-
off point of 7.5 mmol/l is used to screen for diabetes in this community?
Jawab:
Tabel 2x2 of diabetes by true cases against test results
Diabetes by true cases against FBS test results (cut-off 7.5 mmol/l)

Diabetes (GTT) Total


Test results (FBS)
Positive Negative

Positive 36 10 46
Negative 4 950 954
Total 40 960 1000
FBS positive predictive value: 36/46 x 100 = 78%
FBS false negative error rate: 4/40 x 100 = 10%

6. If you were asked to fix the cut-off point of FBS for a survey of your community would
you select 6 mmol/l or 7 mmol/l? Give reasons for your answer.
Jawab:
Titik point 6 mmol / l lebih sesuai untuk digunakan untuk test FBS karena memiliki tingkat
kesalahan negative palsu yang lebih rendah (2,5%) dibandingkan pada tingkat kesalahan negative
palsu dengan titik point 7 mmol / l (5%).
 False positif meningkat menyebabkan stress psikologis dan meningkatnya biaya
 False negative rendah, artinya masih ada individu dengan penyakit diabetes yang lolos dari
tes (hasil negative) sehingga terabaikan dan tidak diobati
Namun masalah tsb bisa diatasi dengan adanya :
 Tes lanjutan diabetesyang bertujuan untuk meminimalkan tingkat stress dan mengkonfirmasi
diagnosis diabetes sebelumnya.
 Pengobatan yang efektif pada penderita diabetes yang dapat mencegah terjadinya komplikasi
diabetes.

Theodora Ferminarti Jati. 15/388240/PKU/15462. Pascasarjana IKM Kesling. Epidemiologi Tutorial 5.


Activity 2
A physical examination was used to screen for breast cancer in 2500 women with biopsy proven
adenocarcinoma of the breast and in 5000 age and race matched control women. The results of the physical
examination were positive (mass was palpated) in 1800 cases and 800 control women, all of whom showed
no evidence of cancer at biopsy.

1. Calculate the sensitivity, specificity and positive predictive value of the physical examination.

Jawab:

Physical examination Biopsy proven Total


adenocarcinoma of the breast
Positif Negatif
Positif 1800 800 2600
Negatif 700 4200 4900
Total 2500 5000 7500

Sensitivity = (1800/2500)x100 = 72%


Specificity = (4200/5000)x100 = 84%
PPV( Positive Predictive Value) = (1800/2600)x100 = 69.2%

Activity 3
Two physicians were asked to classify 100 chests X ray as abnormal or normal
independently. The comparison of their classification is shown in following table:

Physician 1 Physician 2 Total


Abnormal Normal
Abnormal a b 60
40 20
(tests agree) (tests disagree)

Classification of Chest X-Ray by Physician 1 compared with Physician 2

Theodora Ferminarti Jati. 15/388240/PKU/15462. Pascasarjana IKM Kesling. Epidemiologi Tutorial 5.


Normal c d 40
10 30
(tests disagree) (tests agree)
Total 50 50 100

1. The simple, overall percent agreement between two physicians out of the total is
Jawab:
Percent agreement = number of tests that agree/total number of tests
= a+d / a+b+c+d
= 40+30 / 100
= 70/100 = 0,7 = 70%

2. The overall percent agreement between the two physicians, removing the X-rays that both
physicians classified as normal is
Jawab:
a
Overall Percent Agreement = x 100
(Removing X Ray Normal) a+b+c
40
= x 100
40 + 20 + 10
40
= x 100 = 57.1 %
70

a+d 30 + 20 50
Percent Agreement Expected = = = = 50% (0.50)
total 100 100
3. The value kappa is:
Jawab:
Kappa = (percent agreement – chance agreement) / (1 – chance agreement)
= 0,7 – 0,5 / 1 – 0,5
= 0,2 / 0,5
= 0,4

4. This kappa represents which kind agreement? ( excellent or intermediate to good or poor)
Jawab:
The Kappa statistic ranges from +1 (perfect agreement), to 0 (no agreement beyond that
expected from chance), to -1 (perfect disagreement). In general, a Kappa statistic <0.2 is
considered poor agreement, 0.2 - 0.6 is considered fair agreement, and >0.6 is considered
good agreement.
This kappa represent considered fair agreement (intermediate to good) because exist
in range 0.2 - 0.6
Theodora Ferminarti Jati. 15/388240/PKU/15462. Pascasarjana IKM Kesling. Epidemiologi Tutorial 5.
Activity 4 (Homework)
Now it is time for you to explore some of the current challenges in the implementation of screening
policies. Use the Internet or go to a scientific library to look for published evidence on screening
for colorectal cancer. Use this information to explore reasons for and against screening. Given
unlimited resources, would you recommend a policy in your country based on the criteria for
screening?
Jawab:
Langkah awal untuk meninjau kriteria skrining (mengunakan kriteria WHO untuk melihat
penyakit, test dan pilihan pengobatan yang tersedia) Mempertimbangkan beban penyakit di negara
saya dengan mengunakan data prevalensi dan insiden atau dengan menggunakan data dari rumah
sakit yang akan digunakan untuk menyimpulkan total populasi. Kanker kolorektal adalah penyebab
kematian paling umum kedua di Inggris. Mengalami peningkatan tahunan di sejumlah negara-
negara industri. Yang saya ketahui tentang kanker kolorektal yakni bahwa jalur penyakit dimulai
dengan perkembangan polip kolon jinak, proporsi yang akan berkembang menjadi kanker dalam
kondisi genetik dan dalam lingkungan tertentu. Oleh karena itu sangat mungkin untuk mencegah
perkembangan kanker kolorektal dengan mendeteksi dan menghapus polip difase laten jinak dari
penyakit, yang diduga berlangsung sekitar 10 tahun.Test yang tersedia untuk mendeteksi kanker
kolorektal . Melihat literatur, belajar tentang deteksi okultisme tinja darah (FOB Faecal Occult
Blood ). Sebuah tes FOB sederhana. Pengujian FOB memiliki keterbatasan, namun, seperti yang
telah ditemukan dalam percobaan untuk mendeteksi hanya sebagian kecil dari kanker terdeteksi
layar. Test lain adalah teknik endoskopi (sigmoidoskopi fleksibel dan kolonoskopi), yang dapat
digunakan untuk mencari polip usus dan menghapusnya sebelum mereka menjadi ganas.
Endoskopi juga dapat mendeteksi dan biopsi lesi kanker.
Skrining ini mungkin akan mendeteksi lebih dari 90-95% dari kanker dan polip besar
padatahap awal dan dengan demikian mengurangi angka kematian akibat kanker kolorektal.
Keterbatasan screening dengan sigmoidoscopy adalah bahwa proporsi kanker akan berkembang di
segmen usus yang tidak bisa dijangkau oleh yang sigmoidoscope. Sebuah kolonoskop dapat
digunakan untuk memeriksa seluruh rektum dan usus besar tetapi menimbulkan peningkatan risiko
perforasi usus, yang merupakan komplikasi yang sangat serius. skrining tidak akan efektif jika
tidak patuh, tes endoskopi invasif dapat mengurangi kepatuhan terhadap program skrining, pasien
cenderung merasa tes ini tidak nyaman. Setelah kanker dan pra-kanker terdeteksi, menunjukkan
bukti bahwa operasi pengangkatan polip dan kanker dini akan memiliki dampak yang signifikan
pada morbiditas dan kematian terkait dengan penyakit dibandingkan dengan pengobatan kanker
kolorektal, yang masih memiliki ketahanan hidup 5 tahun hanya 40%. Seorang pembuat kebijakan
juga harus mempertimbangkan sumber daya yang dibutuhkan untuk melaksanakan program
screening. Dalam kasus endoskopi skrining sejumlah besar dokter dan perawat yang terlatih sangat
dibutuhkan untuk melaksanakan skrining, pengobatan, perawatan dan rehabilitasi.

Theodora Ferminarti Jati. 15/388240/PKU/15462. Pascasarjana IKM Kesling. Epidemiologi Tutorial 5.


TUTORIAL EPIDEMIOLOGI 5

SCREENING AND DIAGNOSIS TEST

THEODORA FERMINARTI JATI

15/388240/PKU/15462

JURUSAN KESEHATAN LINGKUNGAN


PROGRAM STUDI PASCA SARJANA ILMU KESEHATAN MASYARAKAT
UNIVERSITAS GADJAH MADA
YOGYAKARTA

Theodora Ferminarti Jati. 15/388240/PKU/15462. Pascasarjana IKM Kesling. Epidemiologi Tutorial


5.