Patient 1 (case scenario)

- 20% pneumonia
- Also sounds like URTI, LRTI
- CXR
o Cons: Inconvenience, cost, small amount of exposure to radiation
o Pros: Rule out/in pneumonia, if pneumonia is caught then he won’t get worse
- Whether CXR given or not depends on values and preferences
Patient 2
- Upon Px there is no air entry
- 85% pneumonia
- CXR
o Management will differ
o If you don’t do CXR and give antibiotics (b/c high probability), can develop
resistance, there are downsides to antibiotics
o Severity of disease
o A Hx of CXR  follow a patient over time, monitor progress

Diagnosis of ambulatory community-acquired pneumonia

Sites: 3 Primary care clinics and 1 ER

Patients: adult, >21 yo, acute febrile illness, <1 week duration (patient report, neighborhood
clinic, ER temperature), at least ¼ complaints (cough, coryza – runny nose, sore throat or
hoarseness), pregnant women and HIV status excluded

Methods: Hx + Px then CXR

Validity:
- patient population that was chosen is too ‘broad’  if every patient w/ just hoarseness
and fever the other day is put into the study, the population leans more towards
‘normal’ rather than ‘abnormal’
- this makes your study look better  physicians will most likely diagnose patients w/out
pneumonia as not having pneumonia (b/c it is obvious in the choice of population) and
vice versa
- the 2 normal distributions will be plotted as further apart from each other
- this will overestimate the power of the test
- could have included some SOB in criteria
- independent comparison
o people doing the test were unaware of results of GS and vv
o separate respirologist and radiologist doing CXR and they were blinded
- risk of bias (from 0-10) is estimated to be 5-6
o met criteria of independent and blind study but not really w/ appropriate
population
Pretest Probability
Posttest Probability

Sensitivity
- Portion of people that are correctly identified in those who are target positive
- 14/19 = 74%

Specificity
- portion of people that are correctly identified in those who are target negative
- 194/231 = 84%

Negative Predictive Value

- post test probability if test is negative

Positive Predictive Value

Conclusions
- physicians are good at ruling out but not ruling in
- when are they right/wrong

Nature of Problems
Validity
- the use of correct methods to find the truth
- risk of bias
- Give skewed results, misled
o Wrong methods used  Bias (systematic deviation from the truth)
o Interpret accurate results in a misleading way
o Random error
 Particularly if sample size is small
- Bias
o systematic deviation from the truth
Results
- random error

Applicability
- inappropriate patient population (symptoms, etc.)
- inappropriate outcome measures  find the truth about something else

Target condition
- the truth
- ie. pneumonia or no pneumonia
- participants are target positive or target negative
- should enroll people w/ diagnostic uncertainty
- use test in people who are going to use the test
Criteria for validity of diagnostic test study
- Appropriate population  people with diagnostic uncertainty
- independent and blind test – gold standard
Criteria for validity of treatment study
- randomization
-

Independent and blind test

- person using GS is not aware of results from physician*

** Find out post test probability for patients 1 and 2 would differ from 20% and 80% if their CXR
were positive or negative  look into likelihood ratios
**