Screening test (adv)

Rizwanul karim NIPSOM

The relationship between a diagnostic test result and the occurrence of disease

Disease
Present Positive True positive + ve Negative False negative - ve Absent False positive

Test

True negative

Comparison of the Results of a Dichotomous Test with Disease Status

True Characteristics In The population

Test results Positive Negative With Disease True Positive (TP) = Have disease and Have positive Test False negative (FN) = Have disease, but have negative test Without Disease False positive (FP) = No disease, but have positive test True negative (TN) = No disease and have negative test

Sensitivity =

TP TP FN

Specificity =

TN TN FP

TN

FP

FP

TP F N
TP FN

a c

FP
TN

b d

Sensitivity and specificity

Disease
Present
Positive

Absent

a c
a Se ac

b d
d Sp bd

Test
Negative

a PV ab
d PV cd

ac p abcd

 The true positive probability (sensitivity) The false negative probability (1-sensitivity)

The true negative probability (specicity) The false positive probability (1-specicity)

Diagnostic test
Disease
Present
Positive

Absent

PV

a ab
d cd

Test
Negative
Se = Sensitivity; Sp = Specificity P = Prevalence; PV = Predictive value; LR = Likelihood ratio, LR+ same as Se/(1-Sp) LR - same as (1-Se)/Sp

c
a Se ac

d
Sp d bd

PV

a LR a c b bd

c LR a c d bd

ac p abcd

example
The true positive probability (sensitivity) The false negative probability (1-sensitivity)

The true negative probability (specicity) The false positive probability (1-specicity)

Pathology present absent Total + positive Liver scan - negative Total 231 27 258 32 54 86 263 81 344

a 231 Sensitivity .895 a c 258

d 54 Specificity .627 c d 86

example
The probability of having disease if you have a positive test is called the positive predictive value (PPV) The probability of not having disease if you have a negative test is called the negative predictive value (NPV)

Pathology present absent Total + positive Liver scan - negative Total 231 27 258 32 54 86 263 81 344

a 231 PPV .878 a b 263 d 54 NPV .666 c d 81

KAPPA
Kappa percent observed agreement - percent agreement expected by chance alone 100% - percent agreement expected by chance alone

Kappa
Pathologist A Grade II Grade II 41 Grade III 3 Totals by B 44 (58.7%)

Pathologist B

Grade III Totals by A

4
45 (60%)

27
30 (40%)

31 (41.3%)
75 (100%)

kappa
Pathologist A Grade II Grade II 41 Grade III 3 Totals by B 44 (58.7%)

Pathologist B

Grade III

4
45 (60%)

27
30 (40%)

31 (41.3%)
75 (100%)

41 27 percent agreement X 100 90.7 % 75 observed

kappa
Pathologist A Grade II Grade II 41 Grade III 3 Totals by B 44 (58.7%)

Pathologist B

26.4

Grade III

4
45 (60%)

27

12.4

31 (41.3%)
75 (100%)

30 (40%)

26.4 12.4 38.8 percent agreement X 100 51.7 % 75 75 expected by chance

kappa
90.7% - 51.7% kappa 100% - 51.7% 39% .81 48.3%

.40 to .75 represents intermediate to good agreement

Likelihood ratio

Likelihood ratio
The Likelihood Ratio (LR) is the likelihood that a given test result would be expected in a patient with the target disorder compared to the likelihood that that same result would be expected in a patient without the target disorder.

example
For example, you have a patient with anaemia and a serum ferritin of 60mmol/l and you find in an article that 90 per cent of patients with iron deficiency anaemia have serum ferritins in the same range as your patient (= sensitivity) and that 15 per cent of patients with other causes for anaemia have serum ferritins in the same range as your patient (1 specificity). This means that your patient's result would be six times as likely (90/15) to be seen in someone with, as opposed to someone without, iron deficiency anaemia, and this is called the LR for a positive test result.

sensitivity LR 1 - specificity

LR

Pr(T D) Pr(T D)

"the probability of a person who has the disease testing positive divided by the probability of a person who does not have the disease testing positive.

Likelihood Ratio
" Here "T+" or "T" denote that the result of the test is positive or negative, respectively. Likewise, "D+" or "D" denote that the disease is present or absent, respectively. So "true positives" are those that test positive (T+) and have the disease (D+), and "false positives" are those that test positive (T+) but do not have the disease (D).

1 - sensitivity LR specificity

LR

Pr(T D) Pr(T D)

or "the probability of a person who has the disease testing negative divided by the probability of a person who does not have the disease testing negative."

example
LR is the increase in odds of disease after a positive test The likelihood ratio can be used to take any prior(pre-test) probability and convert it to a post-test probability. The post-test or posterior probability is the probability that a patient has the disease after a positive test.

Diagnostic test
Disease
Present
Positive

Absent

PV

a ab
d cd

Test
Negative
Se = Sensitivity; Sp = Specificity P = Prevalence; PV = Predictive value; LR = Likelihood ratio, LR+ same as Se/(1-Sp) LR - same as (1-Se)/Sp

c
a Se ac

d
Sp d bd

PV

a LR a c b bd

c LR a c d bd

ac p abcd

Pathology
present absent Total + positive Liver scan - negative Total 231 27 258 32 54 86 263 81 344

a sensitivity ac LR 1 - specificity 1 - d bd a 231 258 ac b 32 bd 86 .895 2.406 .372

 It is the increase in odds of disease after a positive test

Pathology present absent Total

+ positive Liver scan - negative

Total

231 27
258

32 54
86

263 81
344

Pathology

present absent Total + positive

Liver scan - negative Total 231 a 27 c a+c 258 32 b

54 d

a+b 263 c+d 81

b+d a+b+c+d 86 344

ac Pr(D) a b c d ODDsprior bd Pr(D) ab c d ac bd 258 344 3 86 344

Post test probability

After a positive diagnostic test, the odds of disease are referred to as the post-test or posterior odds. ODDS posterior For a 2 X 2 table, it is a matter of simple algebra to show that ODDSposterior = LR+ X ODDSprior

Pathology

present absent Total + positive

Liver scan - negative Total 231 a 27 c a+c 258
P(D T ) P(D T )

32 b

54 d

a+b 263 c+d 81

b+d a+b+c+d 86 344

ODDsposterior

a/(a b) a/b b/(a b) 231/32 7.218

Pathology

present absent Total + positive

Liver scan - negative Total 231 a 27 c a+c 258
a/a c a c X b/b d b d a(b d) a c a X b(a c) b d b

32 b

54 d

a+b 263 c+d 81

b+d a+b+c+d 86 344

ODDsposterior LR X ODDSprior

ODDsposterior LR X ODDSprior 2.406 X 3 7.218

 The likelihood ratio can be used to take any prior(pre-test) probability and convert it to a post-test probability. This allows you to use the results from a diagnostic test and apply them to a population with a different prevalence.

 The odds can be changed back to probabilities by the simple equation

ODDS P 1 ODDS
The post-test or posterior probability is the probability that a patient has the disease after a positive test.

Pathology present + positive Liver scan - negative Total absent a c Total b d a+b 263

231 27

32 54

81c+d
a+b+c+d 344

a+c 258

86b+d

Disease
Present Positive Absent

Test

Negative

a c
Se a ac

b d
Sp d bd

PV
PV

a ab
d cd

a LR a c b bd c LR a c d bd

ac p ab c d

a 231 Sensitivity .895 a c 258

d 54 Specificity .627 c d 86
231 sensitivity 258 2.406 LR 32 1 - specificity 86

Pr(D) 344 3 ODDsprior Pr(D) 86 344

258

ODDsposterior LR X ODDSprior 2.406 X 3 7.218

Pposterior

ODDSposterior 1 ODDSposterior

7.218 0 : 878 1 7.218

The likelihood ratio can be used to take any prior (pre-test) probability and convert it to a post-test probability.
This allows you to use the results from a diagnostic test and apply them to a population with a different prevalence.

 Correspondingly, there is a LR negative

1 sensitivity LR specificity
This tells you the decrease in the odds of having disease if you have a negative test

THANK YOU