Presentasi Dx

8/9/2019 Presentasi Dx

1/31

EBM diagnostic

Kanti Ratnaningrum


2/31

Skenario Klinis

• Seorang anak laki-laki umur 10 tahun datang kedokter dengan keluhan sakit tenggorokan. Sakittenggorokan dirasakan sudah lima hari. Sebagianbesar penyebab faringitis adalah irus. !ang

men"adi fokus perhatian dokter adalahmendiagnosis pasien apakah faringitis inidisebabkan oleh streptokokus #rup $ %#$S&. 'alini membutuhkan pemeriksaan kultur bakteri tapi

memerlukan (aktu lebih dari satu hari) untukmempercepat diagnosis) doktermempertimbangkan penggunaan pemeriksaanlain.


3/31

• *emeriksaankultur merupakan +gold standrat,

untuk mendiagnosis faringitis oleh karena #$S.aktu yang diperlukan untuk pemeriksaankultur ini sekitar /-/ "am.

• $ uantitatie polymerase chain reaction

%*2R& adalah teknik laboratorium biologimolekuler berdasarkan reaksi berantaipolimerase % *2R & yang dapat sedangdikembangkan.

• Sebelum dokter mempertimbangkan perubahanalur diagnosis pasien faringitis) sensiti3tas *2Rdibandingkan dengan pemeriksaan kultur untukmendeteksi #$S


4/31

Steps in Practicing EBM

1. Convert the need for information intoan answerable question.

. 4rack do(n the best eidence (ith (hich toans(er that uestion.

5. 2ritically appraise the eidence for itsalidity) impact) and applicability.

/. 6ntegrate the eidence (ith our clinicale7pertise and our patient’s characteristicsand alues.

8. Ealuating our e9ectieness and e:ciency ine7ecuting steps 1;/ and seeking (ays toimproe them both for ne7t time.


5/31

The clinical question:PICO

Patient orProblem

Intervention

Comparison

Outcome

$nakdengansuspek#roup $

streptococcus %#$S&

$uantitatiepolymerase

chainreaction%*2R&

#oldstandard<kultur

=iagnosisof faringitise.c #$S


6/31


7/31


1. 2onert the need for information into anans(erable uestion.

2. Track down the best evidence with

which to answer that question.5. 2ritically appraise the eidence for itsalidity) impact) and applicability.

/. 6ntegrate the eidence (ith our clinicale7pertise and our patient’s characteristics

and alues.8. Ealuating our e9ectieness and e:ciency ine7ecuting steps 1;/ and seeking (ays toimproe them both for ne7t time.


8/31

The search strategy

• *ubmed database<(http://www.ncbi.nlm.nih.gov/sites/ent rez?db=pubmed)

• ?sing the 2linical @ueries function of*ubMed< – Key (ords<

• “#$S” $A=

• “*2R”

– 2linical Study 2ategories< “=iagnosis”

– Scope< “Aarro(”


9/31

The Evidence

• =etection of group a streptococcalpharyngitis by uantitatie *2R

• =unne EM) Marshall C) Baker 2$) Manning ) #onis #) =anchin M') Smeesters *')SatDke 2) Steer $2. 015. =etection ofgroup a streptococcal pharyngitis byuantitatie *2R. BM2 6nfectious =iseases015) 15


10/31



. 4rack do(n the best eidence (ith (hich to

ans(er that uestion.3. Critically appraise the evidence for itsvalidity, impact, and applicability.

/. 6ntegrate the eidence (ith our clinicale7pertise and our patient’s characteristics

and alues.8. Ealuating our e9ectieness and e:ciency ine7ecuting steps 1;/ and seeking (ays toimproe them both for ne7t time.


11/31

ppraising the Evidence

1. 6s this eidence about the accuracyof a diagnostic test alid>

. =oes this %alid& eidencedemonstrate an important ability ofthis test to accurately distinguishpatients (ho do and do not hae a

speci3c disorder>5. 2an 6 apply this alid) important

diagnostic test to a speci3c patient>


12/31

Is this evidence about the accuracy o! adiagnostic test valid"#$ Measurement

– as the reference %“gold”& standard measuredindependently>

!a %halm dari F&


13/31

Is this evidence about the accuracy o! adiagnostic test valid"%$ &epresentative

– as the diagnostic test ealuated in an appropriatespectrum of patients %those in (hom (e (ould use itin practice&>

!a


14/31

Is this evidence about the accuracy o! adiagnostic test valid"'$ scertainment

– as the reference standard ascertained regardless ofthe diagnostic test result>

!a


15/31

re the results o! this studyvalid"

• !a


16/31







17/31


18/31

4abel 7

spy12!

• Sensiti3tas< 1%1G5&. 100H FI benar-benar (+) G!

• Spesi3sitas< 105%0G105&.100H 100I benar-benar (-) G!• **J< 1%1G0&. 100H 100I

100I dari pasien yang dinyatakan %G& adalah benar disebabkan #$S

• A*J< 105%5G105&.100H FI

FI dari pasien yang dinyatakan %-& benar-benar tidak disebabkanoleh #$S


19/31

• Sensiti3tas 100I

• spesi3sitas 100I

• *realensi carier faringitis #$S 1I

%Shaikh A et al. 010&


20/31







21/31

re the results o! this diagnostic studyapplicable to my patient"

1. 6s the diagnostic test aailable)a9ordable) accurate) and precise in our

setting>• !a) akurat dan tersedia %tetapi tidak di semua

laboratorium&

• 4etapi tidak ter"angkau untuk semua pasien

%hanya keluarga kalangan menengah ke atas&• =an belum tepat dilakukan karena berbagai

pertimbangan


22/31

re the results o! this diagnosticstudy applicable to my patient"

. 2an (e generate a clinically sensibleestimate of our patient’s pre-testprobability>

a. Lrom personal e7perience) prealence statistics)practice databases) or primary studies.• !a

b. $re the study patients similar to our o(n>• !a

c. 6s it unlikely that the disease possibilities haechanged since this eidence (as gathered>

• !a


23/31

(i)elihood &atio

SpeB

• Likelihood Ratio+ = sens/(1-spec) = 100/(100-100) = ~• Likelihood Ratio- = (1-sens)/spec = (100-100)/100 = 0

• Pe!alence = (a+c)/(a+"+c+d) = #$/1#% = 1&'

• *td, pe-test odds = pe!alence/(1-pe!alence) = 1&'/&1'1 = #'

• Post-test odds = pe-test odds . likelihood atio = #' . * = ~

• Post-test po"a"ilit, = post-test odds/(post-test odds +1) = * / * = *


24/31


25/31


26/31

re the results o! this diagnosticstudy applicable to my patient"

5. ill the resulting post-testprobabilities a9ect our

management and help our patient>1. 2ould it moe us across a test-

treatment threshold>• !a) dari pre-test probability of 1.I ke

post-test probability of *

re the results o! this


27/31

re the results o! thisdiagnostic study applicable to

my patient"5. ill the resulting post-test probabilities

a9ect our management and help ourpatient> %cont.&

. ould our patient be a (illing partner incarrying it out>

• Mungkin iya

5. ould the conseuences of the test help ourpatient reach his or her goals in all this>

• !a) "ika hasil %-&) "ika hasil %G& dapat membantudalam hal pengobatan dan pencegahan komplikasiseperti =R$ dll


28/31





". #nte$rate the evidence with our clinicale%pertise and our patient ’ scharacteristics and values.

8. Ealuating our e9ectieness and e:ciency ine7ecuting steps 1;/ and seeking (ays toimproe them both for ne7t time.


29/31

+o, can I apply the results topatient care"

• 4es *2R spe" ini sangat bagus karena memilikisensiti3tas dan spesi3tas tinggi) sehingga dapatdigunakan untuk meningkatkan ketepatandiagnosis dan dan terapi serta mencegah

komplikasi

• 4es *2R mungkin tidak efektif dari segipembiayaan dan keter"angkauan karena tidaksemua laboratorium memiliki fasilitas *2R ini

• berbagai faktor harus dipertimbangkan sebelumpenggunaan tes *2R dalam strategi diagnosis)terapi dan pencegahan komplikasi


30/31





/. 6ntegrate the eidence (ith our clinicale7pertise and our patient’s characteristicsand alues.

. &valuatin$ our e'ectiveness ande(ciency in e%ecutin$ steps 1)" andseekin$ ways to improve them both forne%t time.


31/31

4erimakasih

Presentasi Dx

Documents

Transcript of Presentasi Dx