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CONCEPT OF SCREENING
Search for unrecognised disease or defect by means of rapidly applied tests, examinations or other procedures in apparently healthy individuals.
CONCEPT OF SCREENING
Search for unrecognised disease or defect by means of rapidly applied tests, examinations or other procedures in apparently healthy individuals.
HISTORY
Originally done for individual disease like TB, syphilis in selected groups like under5 children, antenatal women, etc Now considered as an extension of health care
Diagnostic tests
Done in persons with indication or sick Applied to single patients Diagnosis not final but modified on the light of new evidence Based on evaluation of a number of symptoms/ signs
Diagnostic tests
More accurate More expensive
Not a basis of treatment Usually a basis of treatment Initiative comes from investigator or agency providing care. Initiative comes from patient with a complaint.
OUTCOME
A
SCREENING TIME
LEAD TIME
LEAD TIME
Advantage gained by screening i.e., period between diagnosis by early detection and diagnosis by other means. Equals the amount of time by which treatment is advanced or made early Does not imply improved outcome!! Necessary but not sufficient condition for effective screening.
12
To bring those who are apparently abnormal under medical supervision and treatment. Carried out in hope that earlier diagnosis and subsequent treatment favourably alters the natural history of disease in significant proportion of those who are identified as positive. Ultimate objective: to reduce mortality and morbidity
SOME TERMS
Screening Case finding Diagnostic tests
USES OF SCREENING
Case detection: Prescriptive screening
Presumptive identification of unrecognized disease which does not arise from a patients request Eg. Breast cancer, cervical cancer
Research purpose:
To find out the natural history of chronic disease
Educational opportunities:
Creating public awareness
TYPES OF SCREENING
Mass screening High risk or selective screening Multiphasic screening
MASS SCREENING
Screening of a whole population or a sub group eg: all adults Offered to all , irrespective of the particular risk the individual may run of contracting the disease in question Indiscriminate use- not a useful measure unless backed by suitable treatment
MULTIPHASIC SCREENING
Application of two or more screening tests in combination to a large number of people at one time May include a health questionnaire, clinical examination and a range of measurements and investigations
Facilities should be available for confirmation of diagnosis There is an effective treatment There should be an agreed on policy concerning whom to treat as patients There is good evidence that early detection and treatment reduces morbidity & mortality The expected benefits (eg. No. of lives saved) of early detection exceed the risks and costs.
ACCEPTABILITY
Acceptable to the people to whom it is aimed Tests that are painful, discomforting or embarrassing are not likely to be acceptable
REPEATABILITY
Also known as r eliability, precision or reproducibility Test must give consistent results when repeated more than once on the same individual or material, under the same conditions. Depends upon:
Observer variation Biological (subject) variation Errors relating to technical methods
OBSERVER VARIATION
Intra observer variation/ within observer variation Inter observer variation/ between observer variation
VALIDITY (ACCURACY)
Refers to what extent the test accurately measures which it purports to measure The ability of a test to separate or distinguish those who have the disease from those who dont Two components:
Sensitivity specificity
Negative
c+d
Total
a+ b + c + d
SENSITIVITY
Statistical test for diagnostic accuracy Ability of the test to identify correctly all those who have the disease i.e., true positive 90% sensitivity- 90% of the diseased people screened by the test will give a true positive result whereas 10% will give a false negative result Formula: a X 100 a+ c
SPECIFICITY
Ability of test to identify correctly those who do not have the disease i.e., true negative 90% specificity- 90% of non diseased people will give true negative result. Formula: d X 100 b+d
360 60 420
40 1540 1580
Calculate sensitivity, specificity, positive predictive value and negative predictive value.
FALSE NEGATIVES
Patients who actually have the disease are told that they do not have the disease Giving them false re-assurance Could be detrimental if the disease in the question is a serious one A very sensitive test has few false negatives; lower the sensitivity, higher the no. of false negatives
FALSE POSITIVES
Patients who do not have the disease are told that they have Normal healthy people are subjected to further diagnostic tests, at some inconvenience, discomfort, anxiety and expense- until their freedom from disease is established Bring discredit to the screening program
YIELD
The amount of previously unrecognised disease that is diagnosed as a result of screening effort Depends upon sensitivity, specificity, prevalence of the disease, participation of individuals High risk screening increases the yield
COMBINATION OF TESTS
Two or more tests can be used in
Series Parallel
PROBLEM OF BORDERLINE
BIAS IN SCREENING
Patient selection Lead time Length time
THANKS