DR.Dr.

JULIANDI HARAHAP, MA
Dept. of Communitiy Medicine
FK USU
 Establishingdiagnosies is an imperfect
process, resulting in a probability rathar than
a certainty of being right.

A simple way of looking at the relationships

between a test’s results and the true
diagnosis is shown in table below:
 Thetest is considered to be either positif or
negatif and the disease is either present or
absent.

 The test has given the correct answer when

it is positive in the presence of diseses or
negative in the absence of the disease.

 Thetest has been misleading if it is positive

when the disease is absent or negative when
the disease is present
PARALEL TEST: TEST A and TEST B and TEST C ARE POSITIVE

A

B
 C

SERIAL TEST: TEST A or TEST B or TEST C IS POSITIVE

ABC
 A screening test is done to detect potential
health disorders or diseases in people who do not
have any symptoms of disease.

 The goal is early detection and lifestyle changes

or surveillance, to reduce the risk of disease, or
to detect it early enough to treat it most
effectively.

 Screening tests are not considered diagnostic,

but are used to identify a subset of the
population who should have additional testing to
determine the presence or absence of disease.
a b

c d
 Target disorder Totals
(iron deficiency anemia)
Present Absent
Diagnostic Positive 731 270 1001
test result (< 65 mmol/L) a b a+b
(serum Negative 78 1500 1578
ferritin) ( 65 mmol/L) c d c+d
Totals 809 1770 2579
a+c b+d a+b+c+d

Sensitivity = a/(a+c) = 731/809 = 90%

Specificity = d/(b+d) = 1500/1770 = 85%
Likelihood ratio for a positive test result = LR+ = sens/(1-spec) = 90%/15% = 6
Likelihood ratio for a negative test result = LR - = (1-sens)/spec = 10%/85% = 0.12
Positive Predictive Value = a/(a+b) = 731/1001 = 73%
Negative Predictive Value = d/(c+d) = 1500/1578 = 95%
Pre-test probability (prevalence) = (a+c)/(a+b+c+d) = 809/2579 = 32%
Pre-test odds = prevalence/(1-prevalence) = 31%/69% = 0.45
Post-test odds = pre-test odds  LR
Post-test probability = post-test odds/(post-test odds +1)
 Sensitivity:the percentage of persons with
the disease of interest who have positive test
results.
= a/(a+c) x 100

 Specificity:the percentage of persons

without the disease of interest who have
negative results.
= d/(d+b) x 100
 PPV: the percentage of persons with positive
test results who actually have the disease of
interest.
= a/(a+b) x 100

 NPV: the percentage of persons with negative

test results who do not have the disease of
interest.
= d/(d+c) x 100
 Likelihood is the probability of a particular
test result for a person with the disease of
interest divided by the probability of that
test result for a person without the disease
of interest.

 Likelihood Ratio for a positive test result

(LR+)
 Likelihood Ratio for a negative test result
(LR-)
 (LR+)is the probability of a positive test result
for a person with the disease of interest divided
by the probability of a positive test result for a
person without the disease.

 LR+ = Sensitivity / (1-Specificity)

 LR+ > 1: persons affected with disease of
interest are more likely to have a positive test
result than unaffected persons.
 The larger the value of the LR, the stronger the
association between having a positive test
result and having the disease of interest.
 LR+ value of 10 or greater is perceived as
indication of a test of high diagnostic value.
 LRs >10 or <0.1 cause large changes in
likelihood.
 LRs 5-10 or 0.1-0.2 cause moderate
changes.
 LRs 2-5 or 0.2-0.5 cause small changes.
 LRs between <2 and 0.5 cause little or no
change
 Pretestprobability of disease: the probability that a
person has the disease of interest before the test is
performed.
= prevalence

 Pretest odds of disease: the estimate before

diagnostic testing of the probability that a patient
has the disease of interest divided by the
probability that the patient does not have the
disease of interest.
 Pretest odds= pretest probability/(1-pretest
probability)
 Posttest odds of disease: as the estimate after
diagnostic testing of the probability that a patient has
the disease of interest divided by the probability that
the patient does not have the disease of interest.
 Posttest odds= pretest odds x LR +

 Posttest probability = posttest odds/ (1+posttest odds)

 a result of obtaining a positive test result, the

estimated probability of the presence of disease has
risen from 0.08 (pretest probability) to 0.76 (posttest
probability).

 Diagnostic tests that produce big changes from

pretest to post-test probabilities are important and
likely to be useful to us in our practice
 Another way to express the relationship between
sensitivity and specificity is to construct a curve
 RECEIVER OPERATOR CHARACTERISTIC
(ROC) CURVE  plotting the true positive rate
(sensitivity) against false positive rate (1 –
specificity) over a range of cut-off values
Roc curve-1
 Test that discriminate well toward the
upper left corner of the roc curve  as the
cut-off point is lowered  sensitivity is
progressively increased and there is little
or no loss of specificity
 Can be used to decide  the best cut-off
point  near the “shoulder” of the roc
curve
 Particularly valuable ways of comparing
alternative tests for the same diagnosis
 The overall accuracy of a test can be
describe as the “area under the roc curve”
 the larger the area the better the test
Roc curve--2