CRITICAL APPRAISAL DIAGNOSIS

Signs for early diagnosis of heart failure in primary health care

Disusun sebagai tugas blok 1.6 Basic Medical Practice

Disusun oleh :

Guntur Marganing Adi Nugroho (NIM : 11/312303/KU/14350)

Grup C / Kelompok 13 Pendidikan Dokter 2011 Fakultas Kedokteran Universitas Gadjah Mada Yogyakarta Juni 2012

Citation:

Signs for early diagnosis of heart failure in primary health care

Dirk Devroey, Viviane Van Casteren Original research, published in the following Dove Press journal : Vascular Health and Risk Management 13 September 2011

Are the results of this diagnostic study valid?

Blind comparison : Blind tipe 1, karena dokter tahu kalau pasien yang didiagnosis berdasar gejala dan tanda klinis akan dilakukan pengujian lanjut dengan gold standard. The data were collected during a 2-year period from 178 sentinel practices, who participated in the registrations at least 26 weeks a year. The participating family physicians were asked to register all their adult patients without known HF, for whom a diagnosis of HF was suspected for the first time. The observations were initially registered on the weekly registration form, together with other themes in the observation program. The possibility of HF was based on the patients symptoms and clinical signs. Independent : Tidak, karena yang melakukan diagnosis awal dan akhir sama, yaitu dokter keluarga, walaupun pembuatan diagnosis final dilakukan setelah mendapat informasi tambahan. For every recorded patient, the participating family physician was sent an additional in-depth questionnaire 1 month after the initial registration. The physicians then provided additional or more detailed information on diagnostic criteria and complementary examinations, on which the final diagnosis was based. Tingkat kepercayaan dan keakuratan gold standard : Ya, keakuratan gold standard dengan jelas disebutkan dan metode yang digunakan juga sudah terbukti dan pernah dilakukan sebelumnya An electrocardiogram was performed in 75% of the cases, blood analyses in 68%, echocardiogram in 63%, chest X-ray in 61%, and determination of natriuretic peptides in 11% of the cases The data for this study were collected by the Belgian network of sentinel practices. This network serves as a reliable source on the surveillance of morbidity in Belgium, and has been operating with similar methods since 79 1979. The network has already been tested and proven effective as 911 a surveillance system. Similar networks are currently applied in many other countries. . Ya, subjek dari penelitian ini adalah pasien dewasa yang belum pernah menderita gagal jantung dan baru dicurigai secara klinis menderita gagal jantung yang pertama kali. All adult patients without known HF, for which the diagnosis of HF was clinically suspected for the first time, were registered. When diagnosed, HF was confirmed after 1 month. Ya, untuk setiap pasien yang tercatat memiliki berbagai gejala dan tanda klinis gagal jantung akan dilakukan pemeriksaan gold standard, walaupun tidak lengkap, untuk mengetahui tingkat relevan tanda dan gejala klinis tersebut dengan penyakit gagal jantung. For every recorded patient, the participating family physician was sent an additional in-depth questionnaire 1 month after the initial registration. The physicians then provided additional or more detailed information on diagnostic criteria and complementary examinations, on

Was there an independent, blind comparison with a reference (gold) standard of diagnosis?

Was the diagnostic test evaluated in an appropriate spectrum of patients (like those in whom it would be used in practice)?

Was the reference standard applied regardless of the diagnostic test result?

which the final diagnosis was based. Ya, tes ini sebelumnya sudah pernah dilakukan di Belgia pada tahun 1979, dan metodenya juga sudah terbukti efektif dan dilakukan di banyak negara. This network serves as a reliable source on the surveillance of morbidity in 79 Belgium, and has been operating with similar methods since 1979. The network has already been tested and proven effective as a surveil911 lance system. Similar networks are currently applied in many other 12,13 countries. The sentinel practices are distrib -uted evenly over the Belgian territory by means of a cluster analysis, based on epidemiological 7,8 criteria. The network of sentinel practices consists of family physicians who, with respect to age and gender, are representative of family physicians in Belgium. The yearly adult sentinel population during the registration period was estimated to be 143,705 or almost 1.8% of the Belgian adult population.

Was the test (or cluster of tests) validated in a second, independent group of patients?

Are the valid results of this diagnostic study important? 754-372-74=754-446=308

SAMPLE CALCULATIONS Dari banyak data yang disajikan dipilih contoh yang memliki sensitivitas dan spesifisitas tertinggi yaitu kehabisan nafas saat berolahraga. Pathological diagnoses Present Absent 372 74 kehabisan nafas saat berolahraga. Totals Positive a 185 Negative c 557 a+c d 197 b+d c+d 754 a+b+c+d b 123 a+b 308 Totals

446

Sensitivity=a/(a+c)= 372/557 = 67% Specificity=d/(b+d)= 123/197 = 62% Likelihood ratio for a positive test result=LR+=sensitivity/(1specificity)= 0.67/0.38 = 1.76 Likelihood ratio for a negative test result=LR=(1sensitivity)/specificity= 0.33/0.62 = 0.53 Positive predictive value=a/(a+b)= 372/446 = 83% Negative predictive value=d/(c+d)= 123/308 = 40% Pre-test probability (prevalence)=(a+c)/(a+b+c+d)= 557/754 = 74% Pre-test odds=prevalence/(1 prevalence)= 0.74/0.26 = 2.85 Post-test odds (1) =(pre-test odds) LR+= 2.85 x 1.76 = 5 Post-test odds (2) =(pre-test odds) LR-= 2.85 x 0.53 = 1.51

Post-test probability (1) =(post-test odds)/(post-test odds+1)= 5/6 = 0.83 Post-test probability (2) =(post-test odds)/(post-test odds+1)= 1.51/2.51 = 0.6