Documente Academic
Documente Profesional
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MAKING
Putu Moda Arsana
Dogmatism
Expert knowledge
(qualitative)
Paternalism
Patient as
co-producer
Transparency
Study evidence
(quantitative)
Statistical
(un-)certainty
Pragmatism Empirism
Modified from: Prof. Ulrich Trhler, University of Freiburg, 1999
Medical decision-making
Clinical Process
Diagnosis
Process
Keluhan
Therapeutic
process
Diagnosa
Clinical Process
Terapi
Diagnosis
Process
Keluhan
Diagnosa
Therapeutic
process
Terapi
Therapy
an action or intervention that can potentially improve care or prevent
diseases or conditions.
What is the best treatment for this disease or condition?
Etiology
the cause of a disease, condition or situation. It may also be referred to as
harm or causation.
What is the cause of my patients disease or condition?
Prognosis
the progression of a treated disease.
What outcome can be expected from the treatment/intervention used?
Definitions from McKibbon, 2009
Diagnostic Testing
Decision
Decision Making
Making
Biochemical
BiochemicalAssay
Assay
Clinical
ClinicalFinding
Finding
Radiologic
Radiologicprocedure
procedure
Biopsy
Biopsy
Diagnostic Testing
Diagnostic Testing
Clinical
Clinical
Question
Question
EBM Principles
EBM Principles
Sensitivity
Sensitivity
Specificity
Specificity
ROC-Curve
ROC-Curve
Likelihood
LikelihoodRatio
Ratio
Predictive
PredictiveValue
Value
Diagnostic
DiagnosticAccuracy
Accuracy
Validity
Reliability
Clinical relevance
Feasibility
Cost
Validity (accuracy)
Reliability (Reproducibility,
precision)
Properties of test
Sensitivity
Specificity
Predictive value of positive test
Predictive value of negative test
Likelihood ratio of positive test
Likelihood ratio of negative test
Pretest probability
Posttest probability
Company Logo
specificity
Disease
Present
Absent
positive
True-positive
(a)
False-positive
(b)
negative
False-negative
(c)
True-negative
(d)
a+c
b+d
Test result
hypothyroidism
Present
Absent
high
99
(a)
99
(b)
normal
1
(c)
9801
(d)
100
9900
TSH result
N= 10,000
hypothyroidism
Present
Absent
high
990
(a)
90
(b)
normal
10
(c)
8910
(d)
1000
9000
TSH result
N= 10,000
DECISION ANALYSIS
LR+ = Sensitivity/(1-Specificity)
LR- = (1-Sensitivity)/Specificity
Likelihood ratios
= sensitivity/false-positive = sensitivity/(1specificity)
The higher ratio (>1) , the better the test
Likelihood ratios
Sensitivity = a/(a+c)
Specificity = d/(b+d)
LR+ = [a/(a+c)]/[b/(b+d)
LR- = [c/(a+c)/d(b+d)]
Prevalence = (a+c)/(a+b+c+d)
Odds = (a+c)/(b+d)
Disease
Present
Absent
positive
True-positive
(a)
False-positive
(b)
negative
False-negative
(c)
True-negative
(d)
a+c
b+d
Test result
Interpretation of Likelihood
Ratios
Likelihood ratio +
The higher, the better
LR+ >10
conclusive changes
from pre- to posttest probability
1-2 rarely
important changes
Likelihood ratio
Closing to 0 is better
LR- <0.1
conclusive changes
from pre- to posttest probability
0.1-0.2 moderate
shift
0.2-0.5 small
changes in
probability
0.5-1 rarely
important changes
Test
20
FNAB
Malignant 226(4.4-11.7)
guided with Suspicious 1.3 (0.52-3.2)
U/S
Insufficien 2.7 (0.52-15)
t
7-22
132
868
FNAB not
guided
Result
LR(95%CI)
benign
0.24 (0.110.52)
Malignant
34 (15-74)
Characteristics of laboratory
tests in thyroid disorders
test
Se
Sp
LR
+
LR
-
90.
0
96.
0
99.
0
90.
0
96.
0
99.
0
9.0
24.
0
99.
0
0.1
1
0.0
4
0.0
1
Primary hypothyroidism
Total T4
90.
85.
6.0
0.1
hyperthyroidism
Total T4
T3 RIA
TSH
LR+
=[sensitivity]/[false positive error]
= [sensitivity]/[1-specificity]
=90/[100-85]
=90/15 = 6
Se
Sp
LR+
LR-
94
0.5
1.0
Hard to palpation
42
89
3.8
0.54
31
94
5.2
0.73
83
25
1.1
0.68
95
18
1.2
0.28
85
25
1.1
0.6
74.0
FNBA: suspicious
1.2
0.09
Local pain
FNBA: benign
Se
Sp
LR+
LR-
83.0
67.0
2.5
0.16
96.0
96.0
24.0
0.04
94.0
91.0
10.0
0.07
Low-dose dexamethasone
suppression: urine free cortisol >
0.019-0.025mg/day
95.0
97.0
32.0
0.05
90.0
79.0
4.3
0.13
Cushings syndrome
Cushings disease
High-dose dexa- suppression test
Urine free cortisol suppressed >
50%
Probability of having
disease
Pre-test probability
= prevalence of disease
pre-test odds of disease
Post-test probability
LR+
Calculation of post-test
probability
Post-test probability
Calculation of post-test
probability of disease
1.
2.
3.
4.
5.
1.
2.
3.
4.
5.
Hypothyroidism: TSH
level
Pretest probability =
20%
Odds of
hypothyroidism =
20:80 = 1:4
LR+ for TSH in
hypothyroidism = 99
1:4 x 99 = 99:4
99/(99+4) = 96%
Decision Analysis
1
3
4
Sensitivity Analysis
pre-test probability
Diagnosis
Process
Keluhan
Diagnosa
Therapeutic
process
Terapi
Therapy
an action or intervention that can potentially improve care or prevent
diseases or conditions.
What is the best treatment for this disease or condition?
Etiology
the cause of a disease, condition or situation. It may also be referred to as
harm or causation.
What is the cause of my patients disease or condition?
Prognosis
the progression of a treated disease.
What outcome can be expected from the treatment/intervention used?
Definitions from McKibbon, 2009
Decision Tree
Validity
Importance
Applicability
Thank You !