Screening

Owais Raza | PhD Epidemiology | Tehran University of Medical Sciences

Definition
Application of a test to people who are as yet asymptomatic for the purpose of classifying them with respect to their likelihood of having a particular disease

Screening test DOES NOT diagnose illness

Types of Screening
Mass screening
Multiple / multi phasic screening

Whole population.
Several screening test at the same time. Groups with specific exposure. Patient who consult doctor for some other purpose.

Targeted screening
Case finding/ opportunistic screening

Diseases Appropriate For Screening

Serious Early treatment should be more beneficial High prevalence e.g.
Hypertension Cervical cancer

Screening Test
Inexpensive Easy to administer Minimal discomfort to participants Test should be have
Validity Reliability

Validity & Reliability

consistent but wrong Inconsistent & wrong estimate

valid group estimate, but inconsistent

Consistently estimating target

Reliable Not valid

Valid Not reliable

Neither reliable Nor valid

Reliable & valid

For Dichotomous Variables

Gold Standard Total - ve + ve True +ve (a) False +ve (b) False -ve (c) True -ve (d)
(GT)

+ ve - ve Total

Test

Sensitivity =

TP Specificity = TN TP + FN FP + TN

For Dichotomous Variables

Gold Standard + ve Test Total

- ve 30 (b)
170 (d) 200

+ ve
- ve Total

90 (a)
10 (c) 100

120
180 300

Sensitivity = a / a + c Specificity = d / b + d

For Dichotomous Variables

ForHigher Higher Cutoff Level Cutoff Level

Sensitivity = 25% Specificity = 90%

For Lower Cutoff Level Lower Cutoff Level

Sensitivity = 85% Specificity = 30%

Higher VS Lower cutoff Levels Higher VS Lower Cutoff

If we lower the cutoff
High sensitivity Low specificity

If we higher the cutoff

Low sensitivity High specificity

How to Trade? How To Trade?

Consider the importance of
False Negatives
False good-news Serious disease might be missed in early treatable phase

False Positives
Burden on healthcare system Cost
Physical, emotion, financial

Stigma

Sequential Screening & Simultaneous Screening

Sequential screening
A test is performed on those who tested positive on first screening test

Simultaneous screening
Two screening tests are performed together

Sequential Screening

1st Screening Test Less expensive Less invasive Comfortable

2nd Screening Test Expensive Invasive Less comfortable

Sequential Screening

Sequential Screening

Net Sensitivity: 315 / 500 = 63% Net Specificity: 7600 + 1710 / 9500 = 98% Decrease in sensitivity Increase in specificity

Simultaneous Screening

Test 1

Test 2

Simultaneous Screening
Sen = 80% Spec = 60%

Test 1
160

200 +ve

Sen = 90% Spec = 90%

Test 2
180

200 +ve

200 +ve 16 +ve 36 +ve

144 +ve

Net Sensitivity = (16 + 144 + 36) / 200 Net Sensitivity = 98%

Simultaneous Screening
Sen = 80% Spec = 60%

Test 1
480

800 ve

Sen = 90% Spec = 90%

Test 2
720

800 ve

800 ve 48 ve 288 ve

432 ve

Net Specificity = 432 / 800 Net Specificity = 54%

Sequential Screening & Simultaneous Screening

In sequential testing
Loss of net sensitivity Gain of net specificity

In simultaneous screening
Gain of net sensitivity Loss of net specificity

Sequential Screening VS Simultaneous Screening

Objective
Screening Diagnostic

Length of hospital stay Cost Degree of invasiveness Third party insurance coverage.

Predictive Values
How good is the test at identifying people with the disease and people without disease? If test is positive, what proportion has the disease? Positive Predictive Value If test is negative, what proportion are actually disease free? Negative Predictive Value

Predictive Values
Gold Standard + ve Test Total

- ve 30 (b)
170 (d) 200

+ ve
- ve Total

90 (a)
10 (c) 100

120
180 300

Positive Predictive Value = a / a + b Negative Predictive Value = d / c + d

Relationship between PPV & Disease Feasibility Prevalence

Prevalence (%) PV + (%)

0.1
1.0 5.0 50.0

1.8
15.4 48.6 94.

YIELD

Men screened for hypertension from general population

VS

Only those screened who have family history of hypertension

Relationship between PPV & Specificity of Test

Relationship between PPV & Specificity of Test

Relationship between PPV & Specificity of Test

Relationship between PPV & Specificity of Test

Justification of This Relationship?

Prevalence of most diseases are low Thus, most of the screened population lies on right side of the table So any change on right side will affect greater number of people.

Reliability
Mean reproducibility of results
Intrasubject variation Intraobserver variation

Reliability
Interobserver variation
Quantitatively Percent Agreement
Kappa statistics

Kappa statistics needs:

Percent agreement between observers Percent agreement expected by chance alone Maximum percent that observers could have improved their agreement 100% - percent agreement exp. by chance alone

Reliability
Kappa statistics = (Percent agreement observed) (Percent agreement exp by chance) 100% - (Percent agreement exp by chance)

Kappa statistics = 90.7 51.7 100% - 51.7

= 0.81

< 0.40 Poor agreement 0.40 0.75 Moderate Agreement

> 0.75 Excellent Agreement