DIAGNOSTIC TESTS

Modul Riset

Laboratory study :
- Evaluation of diagnostic tests
- Experimental study : - In vitro
- In vivo

References:
- Pusponegoro HD, et al. Uji Diagnostik. In: S.
Sastroasmoro & S.Ismael (Ed.). Dasar-dasar
Metodologi penelitian klinis. Edisi ke-2.
Jakarta: CV Sagung Seto, 2002.
- Warren S, et al. Designing a New Study III:
Diagnostic Test. In: SB Hulley and SR
Cummings (Eds). Designing a Clinical Research
Baltimore: Williams and Wilkins, 1988.

QUESTIONS
Is Real Time-PCR useful in the diagnosis of
dengue infection?
Among patients with hypertension, is a serum
creatinin level useful in the diagnosis of
renovascular disease?
How good can USG predict breast cancer in
patients with breast tumor?

How well a diagnostic test can differentiate the presence

or absence of a disease.

Purpose of diagnostic tests

1. Diagnosis or exclusion of disease
- The tests must be: sensitive and specific
2. Screening of disease among asymptomatic persons.
Additional test will be needed to confirm early
diagnosis.
The tests are useful when:
- Prevalence of disease is high
- Significant morbidity/mortality without treatment
- Effective therapy is available
- Early treatment gives better outcome.

Purpose of diagnostic test (contd.)

3. Part of the treament
- To monitor disease/ treatment progress
- To identify complication
`
- To monitor drug level
- Determine prognosis
- To confirm indeterminate tests.
- Characterization of causative microorganism
(e.g. drug resistance, genotype)
Important : reproducibility
4. Epidemiology study

Structure
They have :
- Predictor variable (the test results)
- Outcome variable (presence or absence of disease)

The test results as the predictor variable

- dichotomous (positive or negative)
- ordinal (++++, +++, ++, + or -)
- interval (mg of glucose/ mL)
Note: ordinal and interval scales must be changed
to dichotomous scale by using a cutoff point

The disease as outcome variable

- Absence or presence of disease
- Determined by gold standard

2x2 table
Disease status
Test result

Breast cancer

benign nodule

Positif

65

30

Negative

35

70

100

100

Analysis with 2x2

p< 0.001
Statistically the positive result
is highly correlated with presence of disease.
But this test cannot well differentiate absence or presence of disease.

Sensitivity

Is the proportion of subjects with the disease who have

positive test.
A test is called highly sensitive if it shows positive
results in all patients with the disease.
So, it indicates how good a test is at identifying the
diseased

Specificity

Is the proportion of subjects without the disease who

have a negative test.
A test is called specific if it shows negative results in all
patients without the disease.
So, it indicates how good a test is at indicating the
nondiseased

Positive predictive value (PV+) = the

probability that a person with a positive result actually

has the disease.
-

Negative predictive value (PV-) = the probability

that a person with a negative result actually doesnt

have the disease

Disease status
Test result

Breast cancer

Benign nodule

Positif

65

30

Negative

35

70

True positive : the test is positive & the patient has the disease
(65)
False positive : the test is positive but the patient doesnt have
the disease (35)
True negative : The test is negative &the patient doesnt
have the disease (70)
False negative : The test is negative but the patient has the
disease (30)

DISEASE

TEST
RESULT

YES

NO

TOTAL

YES

TRUE
POSITIVE

FALSE
POSITIVE

TP + FP

NO

FALSE
NEGATIVE

TRUE
NEGATIVE

FN + TN

TOTAL

TP + FN

FP + TN

TP + FP +
FN + TN

GOLD STANDARD

TEST
RESULT

POSITIVE

NEGATIVE

TOTAL

POSITIVE

A
(45)

B
(10)

A+B
(55)

NEGATIVE

C
(5)

D
(40)

C+D
(45)

TOTAL

A+C
(50)

B+D
(50)

A+B+
C+D

Sensitivity
= A : ( A+C)
= 90%
Specivicity
= D : (B + D) = 80%
Positive predictive value
= A : (A + B) = 82%
Negative predictive value
= D : (C + D) = 89%

Disease status
Test result

Breast cancer

benign nodule

Positif

70

Negative

30

75

105

100

100

200

Total

Sensitivity

= ?

Specivicity

= ?

PV+

= ?

PV-

= ?

25

Total
95

Disease status
Test result

Breast cancer

benign nodule

Total

Positif

70

25

Negative

30

75

105

100

100

200

Total

Sensitivity

= A : ( A+C)

= 70%

Specivicity

= D : (B + D)

= 75%

PV+

= A : (A + B)

= 73.7%

PV-

= D : (C + D)

= 71.4%

95

Steps in diagnostic test research

1. Identify why a new diagnostic test is necessary

- How good is the present available diagnostic test? Any
weakness?
Can a new method overcome the weakness of the old one?
2. Determine the main purpose of the new test.
- To screen? --- high sensitivity
- To confirm diagnosis? --- high sensitivity and specificity
- To exclude? ---- high specificity
3. Select subject population.
- Screening / Case finding/ Diagnosis
- Location
- Sample number
- Inclusion criteria

4. Select gold standard

- The best available diagnostic test
5. Do the test
- Blinded
6. Data analysis and report
- Sensitivity, Specificity, PV+, PV-.
With confidence interval
- ROC for continuous data

GOLD STANDARD
- Standard method to determine presence or absence
of disease
- Ideally : always positive for diseased person, and
always negative for non-diseased person ---- rare, if
any ----- use the best method available
- One or combination of methods
- Its sensitivity and specificity should not lower than
the new method to be tested.

Cutoff
- When data are in ordinal or numeral
(continuous) scale, we have to decide the point that
differentiate normal and abnormal.
- Depends on the purpose of the test, need high
sensitivity or high specificity.
- E.g : for screening : high sensitivity. To decide
whether
a patient has to undergo a high-risk surgery : high
specificity.

Receiver operator curve

A graph that show the bargain between sensitivity and specificity when
we determine a cut-off point.
Increase sensitivity - decrease specificity, vice versa.
Points closer to diagonal line worse result
Selection of cut-off point depends on the purpose of the test.
x

1.0
x

S
e
n
s
i
t
i
v
i
t
y

0.8
x

0.6
x

0.4

0.2

0.2

0.4

0.6

1 - Specificity

0.8

1.0

Receiver operator curve (ROC) for serum alanine aminotransferase (ALT)

Level (U/L) in the diagnosis of hepatitis
1.0

S
e
n
s
i
t
i
v
i
t
y

25
50

0.8

0.6

100

0.4

200

0.2

400

0.2

0.4

0.6

1 - Specificity

0.8

1.0

The value of diagnostic test also depends on prevalence of

the disease in the population being tested.
Prevalence decrease
less likely that someone with a positive test is
actually has the disease
the more specific a test must be in order to be
clinically useful.

GOLD STANDARD

TEST
RESULT

Prevalence
Sensitivity
Specivicity
PV+
PV-

POSITIVE

NEGATIVE

TOTAL

POSITIVE

A
(45)

B
(10)

A+B
(55)

NEGATIVE

C
(5)

D
(40)

C+D
(45)

TOTAL

A+C
(50)

B+D
(50)

A+B+C+D
(100)

=
=
=
=
=

(A+C) : (A+B+C+D) = 50%

A : ( A+C)
= 90%
D : (B + D) = 80%
A : (A + B) = 82%
D : (C + D) = 89%

GOLD STANDARD

TEST
RESULT

POSITIVE

NEGATIVE

TOTAL

POSITIVE

18

16

34

NEGATIVE

64

66

TOTAL

20

80

100

Prevalence = 20%
Sensitivity
Specivisity
Nilai duga positif
Nilai duga negatif

=
=
=
=

A : ( A+C)
D : (B + D)
A : (A + B)
D : (C + D)

=
=
=
=

90%
80%
55%
97%

Likelihood ratio
= the likelihood that a person with a disease would
have a particular test result divided by the likelihood
that a person without the disease would have that
result.
-This especially useful when a test result is
categorical or continuous.
Positive Likelihood ratio =
a/(a+c) : b/(b+d) = sensitivity : (1-specificity)
Negative Likelihood ratio =
c/(a+c) : d/(b+d) = (1-sensitivity) : specificity

Limitations

1. Random error
- by chance
- quantifiable ---- confidence interval.
2. Systematic error
2.1. Sampling bias :
- When thestudy sample is not representative of the
target population in which test will be used.
2.2. Measurement bias :
- Increase when the person determine the test result
have already known the outcome of gold standard.
- borderline result --- determine in advance how to
treat this result.
2.3. Reporting bias
- Unpromising results usually go unreported.
------ enough samples, so negative results can be
meaningful and reported.

Summary

1. A diagnostic test study determines the usefulness of a

test in the diagnosis of a disease. Good tests are
those that distinguish the diseased from the nondiseased, and are safe, quick, simple, painless, reliable,
and inexpensive.
Randomized blinded trial and usual clinical practice as
model is important in diagnostic test study.
2. In diagnostic test study there is a predictor variable
(test result) and an outcome variable (the disease,
determined by gold standard).
The goal is to describe how strong the association is,
in terms of its sensitivity and specificity.

3. The investigator should determine the sensitivity,

specificity, predictive value of positive test,
predictive value of negative test.
A cutoff point must be determined for calling a result
positive.
4. Studies of diagnostic tests are subject to several
biases; the most important are sampling bias,
measurement bias, and reporting bias.
5. Steps in planning diagnostic test study : a) Identify
why a new diagnostic test is necessary; b) Determine
the main purpose of the new test; c) Select subject
population; d) Select gold standard; e) Apply the test
and the gold standard bilndly; f) Analyse and report
data in terms of sensitivity, specificity and predictive
value.

Thank you