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SCREENING FOR DISEASE

ICEBERG PHENOMENON OF DISEASE


Pattern of disease in hospitals is quite different from that found in the community. A large portion of disease is hidden from view than is evident Iceberg- only tip is visible. Tip- overt/ apparent disease Submerged portion Subclinical cases, Carriers Undiagnosed cases

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

Differs from periodic health check ups:


Capable of wide application Relatively inexpensive Requires less physician time

SCREENING & DIAGNOSTIC TESTS


Screening tests
Done on apparently healthy Applied to groups Tests results are arbitrary and final Based on one criterion/ cut off point

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

SCREENING & DIAGNOSTIC TESTS


Screening tests
Less accurate Less expensive

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.

CONCEPT OF LEAD TIME


Disease onset
1st possible point Final critical diagnosis Usual time of diagnosis

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.
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AIM & OBJECTIVES


To sort out from a large group of apparently healthy individuals those likely
To have the disease under study, or To have an increased risk of disease,

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

POSSIBLE OUTCOMES OF SCREENING

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

Control of disease: Prospective screening


People are screened for the benefit of others Screening of immigrants for infectious disease

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

HIGH RISK/SELECTIVE SCREENING


Screening applied selectively to high risk groups; groups defined on basis of epidemiological research. Eg:
Screening for cancer cervix in lower socioeconomic groups Risk factor screening

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

CRITERIA FOR SCREENING


Criteria for disease Criteria for screening test

SCREENING CRITERIA FOR DISEASE


The condition being screened for should be an important health problem (prevalence should be high) There should be a recognisable latent or early asymptomatic phase. The natural history of the condition, including development from latent to declared disease, should be adequately understood There is a test that can detect the disease prior to the onset of the signs and symptoms

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.

CRITERIA FOR SCREENING TESTS


Acceptability Repeatability Validity

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

INTRA OBSERVER VARIATION


If a single observer takes two measurements in the same subject, at the same time, and each time, he obtained a different result Variation between repeated observations by the same observer on the same subject or material at the same time May be minimized by taking the average of several replicate measurements at the same time.

INTER OBSERVER VARIATION


Variaton between different observers on the same subject or material. Eg: one observer examines blood smear and finds MP while the second observer sees the same slide and finds it normal Can be minimised by
Standardisation of procedures for obtaining measurements and classifications Intensive training to all observers Making use of two or more observers for independent assessment

BIOLOGICAL (SUBJECT) VARIATION


Biological variability associated with many physiological variables Fluctuation may be due to:
Changes in the parameters observed. Eg: blood pressure Variations in the way patients perceive their illness Regression to the mean

ERRORS RELATING TO TECHNICAL METHODS


Defective instruments Erroneous calibration Faulty reagents When these errors are large, repeatability is reduced, and a single test may be unreliable

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

SCREENING TEST RESULTS BY DIAGNOSIS


Screening test results Positive Diagnosis Diseased True positives a False negatives c a+c Non diseased False positives b True negatives d b+ d a+b Total

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

PREDICTIVE ACCURACY OF TEST


Two types
Predictive value of a positive test/ positive predictive value Predictive value of a negative test/ negative predictive value

Depends upon sensitivity, specificity and prevalence of the disease

POSITIVE PREDICTIVE VALUE


Indicates the probability that a patient with positive test result has, in fact, the disease in question Formula: a X 100 a+ b

NEGATIVE PREDICTIVE VALUE


Indicates the probability that a patient with negative test result does not have the disease in question Formula: b X 100 b+d

SCREENING TEST (EEG) FOR DIAGNOSIS OF BRAIN TUMOUR


EEG test for brain tumor Coronary angiography Brain tumor No brain tumor Total

Positive Negative Total

360 60 420

40 1540 1580

400 1600 1000

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

Net sensitivity, net specificity

PROBLEM OF BORDERLINE

BIAS IN SCREENING
Patient selection Lead time Length time

EVALUATION OF SCREENING PROGRAM


Randomized controlled trial: One group receives screening test and control group receives no such test. Uncontrolled trial: People with disease detected with screening appear to live longer after diagnosis and treatment than patients who were not screened. Others: Case control studies, comparing trends

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