Family & Community
Medicine Department Evidence Based Diagnosis Lec. 7
Al-Kindy College of Medicine Prof. Dr Yousif
Lecture Objectives: At the end of the lecture the students are expected to
✓ Understand principles and steps of EB diagnosis
✓ Understand the different purposes for doing tests
✓ Appreciate the appropriate means to evaluate tests for those
purposes
✓ Able to interpret and apply the concepts of LHRs of a test in a clinical
setting
➢ Introduction:
✓ When a patient develops a new set of symptoms, they generally ask their physician ‘What
is wrong with me?’, ‘How will it affect me?’ and ‘What can be done about it?’ These
questions relate to diagnosis, prognosis and treatment.
✓ Making an accurate diagnosis is essential to ensure that a patient receives appropriate
treatment and correct information regarding their prognosis.
✓ Diagnosis” is naming the disease that is causing a patient’s illness.
✓ Diagnosis is the process of using history, physical examination, and investigations to
identify the disease responsible for the patient’s complaint.
✓ Evidence-based (EB) diagnosis” is evidence-based use of medical tests to guide treatment
decisions and prognosis identification. Understanding how to use test results to update the
probability of disease can help us interpret test results more rationally.
✓ The Diagnostic process (clinical reasoning), is complex, & errors account for 15%
✓ This process ends up with a decision that varies between starting treatment, asking for
more investigations, or to ignore the condition completely.
✓ EB diagnosis should result in a reduction in errors in decision making.
➢ Why Evidence-based (EB) diagnosis?
✓ EB diagnosis changes the question from “What is the name of this patient’s disease?” to
three questions:
1) “How likely is the patient to have a particular disease ”?
2) “How good is this test for the disease in question ”?
3) “Is the test worth performing to guide treatment?”
✓ In practice, we examine our patients and define the possible causes of their complaints to
end up with an estimated probability for each possible cause that falls somewhere between
these two limits (0 -100%).
✓ For each disorder there are two important thresholds of probabilities:
• The “test threshold”
• The “treatment threshold”
1
Family & Community
Medicine Department Evidence Based Diagnosis Lec. 7
Al-Kindy College of Medicine Prof. Dr Yousif
✓ According to the estimated disease probability we follow one of three strategies:
a. If our estimation falls below the testing threshold, further testing or starting treatment are
not warranted.
b. If our estimation falls somewhere between the testing and treatment thresholds, further
testing is required.
c. If our estimation falls above the treatment threshold, we start treatment. DM patient
present with hypoglycemia, or Asthmatic patient
➢ Clinical Scenario
✓ A 40-year-old woman presents with breast mass She has +ve mammogram
• The mammogram has sensitivity & specifity of 80% & 90 % respectively (If a woman
has breast cancer, the probability is 80% that she will have a +ve mammogram, and
10% +ve probability in cancer-free women).
• What is the probability that this woman with a +ve mammogram actually has breast
cancer? what is the next step in Management?
✓ Estimate pretest probability, can be achieved from:
• Physicians make a diagnosis in 70–90% of cases from the history and clinic al exam.
• Clinical examination + presence of risk factors + Experience
• Prevalence (Medical practice needs the knowledge of national statistics)
✓ If the physician not crosses the treatment threshold in his/her clinical decision making, a
diagnostic test is needed.
✓ Selection of suitable diagnostic test should be based on best available evidence
✓ The test threshold is the probability below which the physician decides that a certain
diagnosis warrants no further consideration. It depends mainly on
1) the seriousness of the diagnosis
2) the safety of the test
3) the implications of the test on the management of the condition.
✓ In mild diseases, physicians set testing threshold high while in serious diseases they set
testing threshold very low.
2
Family & Community
Medicine Department Evidence Based Diagnosis Lec. 7
Al-Kindy College of Medicine Prof. Dr Yousif
✓ In invasive tests that have serious side effects, as lumbar puncture or biopsy, we tend to
push the test threshold higher and if the test will give us a diagnosis that has no effect on
our treatment, we might also push the test threshold higher.
✓ Can we do all diagnostic tests to all patients? No, Cost, Harm, Misleading, False alarm
✓ We should select a test that has posttest probability differ from pretest probability
✓ After test application: Estimate pretest probability, can be achieved from:
• Likelihood Ratio (LHR) +ve (Used when the test is +ve):
The probability of +ve test in person with disease /the probability of +ve test in person
without disease
(LHR) +ve = Sensitivity\ 1-specifity
• LHR -ve (Used when the test is -ve):
The probability of -ve test in person with disease / the probability of -ve test in person
without disease.
(LHR) -ve = 1- Sensitivity \Specificity
✓ Diagnostic error occurs in 10-15%, and associated with greater morbidity, the majority is
considered to be preventable.
✓ Back to the clinical scenario:
• LHR +ve = 0.80 / (1 - 0.90) = 8
• How much more likely are we to find a +ve test result in a person with disease than in a
person without disease.
• In previous example, the mammograph is +ve 8 time in Ca Breast than no breast cancer
• The larger LR+ (>1), the stronger the association between having +ve test result and
having the disease
• LR+ = 1, test of no value.
✓ More calculation in the clinical scenario:
• LHR -ve = (1 - 0.80) / 0.90 = 0.22
• How less more likely are we to find a negative test result in a person with disease than
in a person without disease.
• In the previous example, In –ve test results, the probability of a person with disease is
22 compare t0 100 without.
• Should be less than 1, if LR- = 1, test of no value.
✓ Advantages of LHR
• Incorporate sensitivity and specificity
• Not influenced by prevalence of disease .
• Can be used to estimate posttest probability from pretest probability and used fin EBM .
• Choose among alternative the best diagnostic test
3
Family & Community
Medicine Department Evidence Based Diagnosis Lec. 7
Al-Kindy College of Medicine Prof. Dr Yousif
Using a nomogram
✓ Calculation of posttest probability with
Likelihood Ratio Nomogram
✓ Or by adding a fraction
✓ So posttest probability in +ve test is =
40% (pretest) + 40% (LHR+=8) = 80%
✓ And the posttest probability in -ve test is
40% (pretest) +(-30%) (LHR- =0.22)= 10%
LHR + Values > 1 increase the posttest probability LHR - Values 0 to 1 decrease the probability
1 + 0% None 0.1 - 45% Large decrease
2 + 15% Slight increase 0.2 - 30% Moderate decrease
5 + 30% Moderate increase 0.5 - 15% Slight decrease
10 + 45% Large increase 1 - 0% Test of No value
➢ Practicing EB Diagnosis (5A)
✓ Assess the problem :
Ex: Search for the fast and accurate diagnostic test for prostate cancer
✓ Ask (PICO):
Is PSA test fast & accurate test for Dx of Ca prostate as compare to histopathology?
• Population: Prostate cancer individuals
• Intervention (Dx test): PSA test
• Comparison: Histopathology
• Outcome: Accurate early diagnosis
✓ Acquire: Cross sectional design
✓ Appraise: Critical Appraisal of medical study
Cross-sectional independent blind comparison with a gold-standard is the method of
choice in assessing new diagnostic modalities. Before accepting the results of such studies
in practice one should thoroughly assess them for their validity, relevance, and results
using a specific sheet for appraising articles about diagnosis.
Relevant to my patient, Valid test (sensitivity, specificity, PV+, PV-, LRH+, LHR-), Less
Cost, Less invasiveness, Compared to gold standard. Change my approach in treatment
✓ Apply:
Advice to use this test to clinical care if the evidence is strong
✓ Diagnosis research is far less advanced than pharmaceutical research. New
pharmaceuticals are subjected to many phases (I, II, III, and IV studies) before approval.
On the other hand, new diagnostic modalities are not subjected to similar studies before
entering the market. Thus, one should be extremely careful before rushing to use a new
diagnostic modality or technique.
