SCREENING

Prepared By Dr. Anees AlSaadi

CMT-P R4
December 2013
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 SCREENING
• Outline:
– Definition of Screening.
– Differentiation between Screening and Diagnostic test?
– Uses/Purpose of Screening.
– Types and Examples of Screening test.
– Criteria for successful screening program.
– Relation ship between sensitivity and specify.
– Risk of Screening.

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How We Can Define Screening ….?

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 Definition
The early detection of:
– Disease
– Precursors of Disease
– Susceptibility to Disease
In individuals who do not show any signs of
disease.

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Definition

The presumptive identification of those who

probably have disease from those who do not
have

by

means of rapidly applied tests in apparently

healthy individuals.
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Definition

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Definition

Screening

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How we can Differentiate Between
Screening and Diagnostic Tests ….?

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Differentiate Between Screening and
Diagnostic Tests
Screening Diagnostic
Asymptomatic Suggestive clinical picture
Large group Single subject
Less accurate Accurate
Not conclusive Conclusive
Less expensive Expensive
Not basic for treatment Basic to treatment

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What are the Uses of Screening ….?

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Uses of Screening
Uses of Screening
Case Detection Perspective Screening

Case / Disease Control Prospective Screening

Research Natural History of Disease

Health Education Public Awareness

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 Purpose of Screening

• Reducing disease burden.

• Classifying people to likelihood of having a

particular disease.

• Mean of identifying high risk groups who

warrant further evaluation.
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Screening Process

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Types of Screening Test

What are the Type of Screening Tests …?

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Types of Screening Test

Types Of Screening
Test Mass

High Risk

Multiphasic

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Types of Screening Test
Population Approach
Not Cost Effective

Potential To Alter The Root Cause Of Disease

Large Chance To Reduce Disease Incidence

Small Benefit To The Individual

Poor Subject Motivation

Large Chance Of Reducing Disease Incidence

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Types of Screening Test
High Risk Strategy

F a i l s To
D eal With
Root Cause
Of Disease.

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Can You Give Some Examples For
Screening Tests … ?

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Examples for Screening Tests
Infancy Pregnancy Elderly Adults

Growth Charts Weight Cancers Lipid profile

Metabolic CBC Depression Blood pressure

Screening

Hearing Test Blood sugar Vitamin BMI

deficiencies

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Criteria For Successful Screening Test:

Criteria for
Disease
Successful
Screening
Criteria for Test

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 Criteria For Successful Screening Test:
• Criteria for Disease:
– Present in population screened.

– High burden &of high public health concern.

– Screening +Intervention must improve

outcome.

– Known natural history of the disease.

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 Criteria For Successful Screening Test:

• Criteria for Test:

– Reliable.
– Valid.
– Simple and inexpensive.
– Very safe.
– Acceptable to subjects and providers.
– Cost-effective.
– Exit strategy.

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Criteria For Successful Screening Test:

• Exit strategy:
• Facilities for diagnosis and appropriate
treatments should be available for positive
subjects.
• Ethically not acceptable to offer screening
without available management.

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Criteria For Successful Screening Test:

What Is The Definition Of

Reliability ?
• RELIABILTY:

What Are The Causes Of

Unreliability ?

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Criteria For Successful Screening Test:

Definition of Reliability:
– Repeatability, Reducibility, Precision.
– Getting the same results, when the test
repeated in same target individuals in the
same settings.

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Criteria For Successful Screening Test:

Causes of unreliability:
– Observer variation.
– Subject variation – Biological.
– Technical method error variation.

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Criteria For Successful Screening Test:

• ACCEPTABILITY:
– The test should not be:
• Painful.
• Unsafe.
• Discomforting /Embarrassing.
• Socially/ believes not accepted.

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Criteria For Successful Screening Test:

VALIDITY:
Ability of the test to distinguish between who
has the diseases and who does not.

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 Sensitivity

Yield Validity Specificity

Predictive
Value
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 DISEASE TOTAL
Diseased No disease
Test +ve a b a+b
TEST

Test -ve c d c+d

TOTAL a+c b+d a+b+c+d

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Sensitivity DISEASE TOTAL

No
Diseased disease
Test a b a+b
Ability of the test +ve

TEST
to truly identify
those who have Test c d c+d
-ve
the disease
TOTAL a+c b+d a+b+c
+d

True Sensitivity=
Positive a/(a+c)

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 Sensitivity

[[A 90% Sensitivity means that 90% of the diseased

people screened by the test will give a “true
positive” and the remaining 10% a “false negative
results”]]

Positive test
Negative test
and have the
and have the
disease.
disease.
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Specificity DISEASE TOTAL

No
Diseased disease
The ability of the test Test a b a+b
to correctly identify +ve

TEST
those who do not
really have the disease Test c d c+d
-ve

TOTAL a+c b+d a+b+c

+d

True Specificity=
Negative d/(b+d)

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 Specificity

[[A 90% Specificity means that 90% of the non

diseased people screened by the test will give a “true
negative” result, and the remaining 10% a “false
negative results”]]

Negative test and do Negative test and have the

not have the disease. disease.
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• False Positive error rate= (1-specificity)

• False Negative error rate = (1-sensitivity)

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Assume a population of 1,000 people 100 have a disease 900
do not have the disease A screening test is used to identify the
100 people with the disease

Sensitivity = 80/ 100 X 100= 80%

Specificity = 800/ 900 X 100 = 88%

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Practical Example
Brain Tumor
EEG Results Present Absent

Positive 36 54,000
Negative 4 306,000
Total 40 360,000

Sensitivity = 36/40 X 100 = 90%

Specificity = 306,000/360,000 X 100 = 85%

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 DISEASE TOTAL
Diseased No disease
Test +ve a (True Positive) b (false Positive) a+b
TEST

Test -ve c (false Negative) d (True Negative) c+d

TOTAL a+c b+d a+b+c+d

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 Predictive value
DISEASE TOTAL

No
Diseased disease
Positive Negative Test a b a+b
Predictive value Predictive value +ve

TEST
Proportion of Proportion of Test c d c+d
Individuals with Individuals with -ve
positive test really negative test really
have the disease have no disease
TOTAL a+c b+d a+b+c
+d
PPV=a/(a+b) NPV= d/(c+d)

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 Practical Example
Screening Test Diagnosis Total
Results
Diseased Not Diseases
Positive 40 20 60
Negative 100 9840 9940
Total 140 9860 10,000

Sensitivity = 40/140 X100 = 28.57%

Specificity = 9840/9860 X100 =99.79%
Positive predictive value = 40/60X100 = 66.66%
Negative predictive value = 9840/9940X100 = 98.9%
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Effects on Predictive Value

Prevalence Increases PPV Increases; NPV Decreases

Prevalence Decreases PPV Decreases; NPV Increases

Specificity Increases PPV Increases

Sensitivity Increases NPV Increases

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 Yield –the amount of previously unrecognized
disease that is diagnosed and brought to treatment as
a result of the screening program.

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Practical Exercise

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What is better a test with high sensitivity
or with high specificity…?

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Relation Between Sensitivity &
Specificity

False
Sensitivity Specificity Positive

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Relation Between Sensitivity &
Specificity

False
Specificity Sensitivity Negative

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Relation Between Sensitivity &
Specificity

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 What
about
Risk of
Screening …?
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Risk of Screening
True False False
Positive Positive Negative

Labelling Delayed
Anxiety
Effect Diagnosis

Fear From Delayed

Future Test Intervention

Monetary
Complications
Expenses
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