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EBM Quiz 1
quiz 1
81
Anatomy
Graduate
02/09/2011

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Term
primary care:
Definition
the first level at which a patient first receives medical attention
Term
secondary care:
Definition
the usual medical care provided in a hospital, nursing home, or by a home health agency
Term
tertiary care:
Definition
refers to highly specialized care in which the most up-to-date sophisticated technology available is utilized (e.g. transplant surgery, specialized intensive care units)
Term
Primary prevention is the institution of measures aimed at _____ ____ or ___ from occuring. Give examples.
Definition
- preventing injury or disease
Vaccination to prevent disease, use of helmets to prevent head injuries, use of condoms to prevent HIV infection, chlorination of water supply to prevent water-borne diseases, use of fluoride to prevent dental cavities, education about hazards (smoking)
Term
Secondary intervention is the institution of measures aimed at ___ or ___ the occurence of ___ ___ or ____ disease, by ___ detection and treatment of the disease. This is aimed at individuals in whom the ___ process has already started but is at the ____ phase. Aimed at ___ ___ of the disease. Give Examples.
Definition
- delaying or preventing the occurence of full blown or symptomatic disease by early detection and treatment of the disease
- disease process has already started but is in asymptomatic stage
- reducing prevalence
Cancer screening, screening for HIV infection, screening for early detection of disease
Term
Tertiary prevention is the prevention of, or limiting the extent of impairment, disability or complications, of disease with the aim of restoring the afflicted patient to a useful, productive life with the highest quality of possible life. Disease has already occurred and been treated clinically, and the aim is to rehabilitate the patient

Examples
Physical therapy for stroke victims, halfway houses for recovered alcoholics, fitness programs for heart attack patients
Definition
Term
Early diagnosis is not a new idea

Attention has shifted to prevention and early detection
More effective
cost-effective means for disease control

More screening technologies are becoming available
Role of whole body scanning?
Virtual colonoscopies?
Definition
Term
Screening is the identification of ____ disease in a given population through the application of tests, examinations, etc. which can be applied ___.
Definition
- unrecognized
- rapidly
Term
Screening separates out those that have the disease from those that do not. It differs from diagnosis, which is the process of confirming an actual case of a disease. It is also different from clinical prediction models. The purpose of screening is to ___ ___ as to whether they are ____to have the disease or be disease free.
Definition
- classify individuals
- likely
Term
Target disorders are relatively rare

Many people need to be screened to find disease

Unforeseen risks, even if rare and minor, may affect large number of screened subjects

Screening test
Diagnosis
Treatment

Benefits affect only few subjects
Definition
Term
positive screening tests can be:
Definition
true positive or false positive
Term
negative screening tests can be :
Definition
true negatives or false negatives
Term
disease can come up with what results:
Definition
- true positive
- false negative
Term
no disease can show what screening results:
Definition
- true negative
- false positive
Term
___ ___ ___ ___ ___ offers guidance on more screening tests. Genetic testing has increased screening methods.
Definition
U.S. Preventative Services Task Force
Term
USPTF-Assesses Evidence
Definition
Cardiovascular Diseases
Congenital Disorders
Infectious Diseases
Mental Disorders and Substance Abuse
Metabolic, Nutritional, and Environmental Disorders
Musculoskeletal Disorders
Neoplastic Diseases
Prenatal Disorders
Vision and Hearing Disorders
Term
characteristics of a good screening test:
Definition
- simple
- rapid
- inexpensive
- safe
- acceptable
Term
Measures used to evaluate screening tests:
Definition
- Validity (accuracy)= sensitivity and specificity
- Reliability (precision/repeatability)
- Yield
- Predictive values (+/-)
Term
Validity is how good the test is at identifying those ___ ____ __ ___ from those that __ __. It is the degree to which the results of a measurement correspond to the ___ state of affairs.
Definition
- that have the disease from those that do not
- true
Term
Sensitivity and Specificity deal with the question:
How good is the test to identify disease and non-disease individuals?
Important public health consideration
Definition
Term
Sensitivity and Specificity are measures used to determine whether or not testing should be done. They are generally regarded as ___ of disease prevalence.
Definition
- independent
Term
Predictive values are calculated ___ the test results and are dependent on ___, ___, and ___ ___.
Definition
- after
- sensitivity, specificity, disease prevalence
Term
Sensitivity measures the ability of a test to ___ ___those __ ___ __ ___. What question does it answer?
Definition
- correctly identify those who have the disease
- Of all of those that have the disease and are being screened, what proportion of them will be identified by the test?
Term
equation for sensitivity:
Definition
sensitivity= [TP/(TP+FN)] x100
Term
Specificity measures the ability of a test to ___ ___ those ___ ___ __ __ __ ___. What question does it answer?
Definition
- correctly identify those who do not have the disease
- Of all of those being screened who do not have the disease, what proportion of them will be identified as disease free?
Term
equation for specificity:
Definition
specificity= [TN/(TN+FP)] x100
Term
To improve sensitivity, the cut point used to classify individuals as diseased should be moved ____ in the range of the ____ individuals.
Definition
- farther in the range of nondiseased individuals
Term
To improve specificity, the cut point should be moved ___ in the range associated with ___ individuals.
Definition
- farther
- disease
Term
sensitivity and specificity have an ___ relationship.
Definition
inverse
Term
Define HTN as systolic BP > 140
Can make test highly specific by using cut-off point of 200 mm Hg
Unlikely to falsely classify people as hypertensive
Sensitivity will be very low, as subjects with BP between 140 and 199 mm HG will be missed
Definition
Term
To increase sensitivy move towards non-diseased, so A would be increased sensitivity.

To increase specificity, move towards diseased, so C would be increased specificity.
Definition
Term
If we ___ the cut off level, you increased the number of individuals who correctly test ____, thus we increase ____. But this also would decrease the proportion who correctly test ____, thus decreasing ____.
Definition
- raise
- negative
- increase specificity
- positive
- sensitivity
Term
So when you increase specificity you increase the number that correctly test negative, but by doing so, you decrease sensitivity meaning you decrease the number that correctly test positive.
Definition
Term
procedures to improve sensitivity and specificity:
Definition
Retrain screeners--reduces the amount of misclassification in tests that require human assessment

Recalibrate screening instrument--reduces the amount of imprecision

Utilize a different test

Utilize more than one test
Term
With tests in series, a subject is classified as ____ only if he/she tests positive in ___ the tests. He/she is classified as ___ if ___ of the tests are ___. Tests are employed in series to improve the ____ of the first test.
Definition
- positive only if all tests are positive
- negative if one of the tests is negative
- specificity
Term
With tests in parallel, a subject is classified as ___ if he/she is ___ in ___ test. Tests are employed in parallel to improve ___ ___, because each test by itself cannot identify all of the cases of disease.
Definition
- positive if any of the tests are positive
- overall sensitivity
Term
tests in series improve ____ of the first test.
Definition
specificity
Term
tests in parallel improve overall _____.
Definition
sensitivity
Term
Repeated measures reliablility is defined as the degree of ___ between or among repeated measurements of the ___ ___ on more than one occasion. This is also referred to as ___ ___ ____.
Definition
- consistency
- same individual
- test-retest reliability
Term
internal consistency:
Definition
- degree of homogeneity within items on a questionnaire
Term
Inter-rater reliability:
Definition
- degree of agreement among trained experts or observers
Term
how to think about reliability and validity in terms of a target.
Definition
- reliability is hitting the same area consistently
- validity is hitting the bulls eye

so results can be reliable but not valid, or valid but not reliable, or both reliable and valid
Term
causes of unreliability/inconsistency:
Definition
Technical error
Sampling error
Observer error (intra-observer and inter-observer variation)
halo effect
lack of blinding
Respondent error
social desirability
Biological error
Term
observer error:
Definition
i think someone has this condition, so I read the results differently
Term
Halo effect:
Definition
= someone filling out eval on a person may already have pre-judgement therefore tend to slant all responses to that opinion.
Term
Social desirability – answer questions based on what is socially acceptable
Definition
Term
biological error
Definition
variability in actual physiology or biology of the phenomena - variability of asthma symptoms, etc
Term
Yield :
Definition
the number of previously unregonized individuals identified by the screening test
Term
the higher the sensitivity the higher the ____.
Definition
yield
Term
The higher the prevalence of unrecognized disease, the higher the ___.
Definition
yield
Term
The more previous screenings there have been, the ___ the yield will be.
Definition
lower
Term
Applying a screening test in areas with limited health care will have ___ ___.
Definition
higher yield

(health behavior affects yield)
Term
predictive value is concerned with test ___.
Definition
results
Term
positive predictive value:
Definition
- the proportion of those that screened positive by the test, that actually have the disease
Term
equation for positive predictive value:
Definition
[TP/(TP + FP)] x100

looking at proportion of all that screened positive, how many have the disease
Term
define negative predictive value:
Definition
- of all those that screened negative, the proportion that actually do not have the disease
Term
equation for negative predictive value:
Definition
[TN/(TN + FN] x 100
Term
disease criteria for a successful screening program:
Definition
- present in the population screened
- high morbidity and/or mortality must be an important public health problem
- early detection and intervention must improve outcome
Term
test criteria for a successful screening program:
Definition
- should be sensitive and specific
- should be simple and inexpensive
- safe
- acceptable to patients and practitioners
Term
risks of screening and getting true positive:
Definition
labeling effect
Term
risk of false positive:
Definition
- monetary expense
- harm from confirmatory tests
- anxiety
- fear of future screens
Term
risks of true negatives:
Definition
- costs and risks of test
Term
risk of false negatives:
Definition
- delayed interventions
- disregard of early signs and symptoms
Term
The number 1 criteria for a mass screening program is that the disease should represent a ___ ___ __ and have a ___, ____, ____ phase. It must be associated with ___ consequences and be ___ ___. Give examples.
Definition
- public health problem
- prevalent,asymptomatic nonmetastatic
- severe
- relatively common
Breast Cancer
 
Colon Cancer
 
Prostate Cancer
 
Cervical Cancer
Term
11 criteria necessary for mass screening program.
Definition
1. Disease of interest should represent a public health problem and have a prevalent, asymptomatic nonmetastatic phase. It must be associated with severe consequences and be relatively common.
2. There should be an accepted treatment for patients with recognized disease.

3. Screening should offer a clear benefit
Lung cancer? Skin cancer?

4. Facilities for diagnosis and treatment should be available.

5. There should be a recognized latent or prolonged early symptomatic stage.

6. There should be a suitable test or examination.

7. The test should be acceptable to the population.

8. The natural history of the condition, including development from latent to declared disease, should be adequately understood.

9. There should be an agreed policy on whom to treat as patients.

10. The cost of screening (including diagnosis and treatment of patients diagnosed) should be economically balanced in relation to possible expenditure on medial care as a whole.

11. Detection of unrecognized disease (in apparently healthy subjects) should be a continuing process and not a once and for all project.
Term
ethical considerations for mass screening:
Definition
- ability to alter natural history
- availability of services
- insurance issues
Term
screening in developing countries:
Definition
The development of advanced screening in developing countries requires special consideration

Local health circumstances must be considered

Unethical to screen without adequate follow-up
Term
Multiphasic screenings use __ or more screening tests together among ___ groups of people. Information is obtained on ___ __ __, __ __ ___, and ___ ___. This is commonly used by ___ and ___ ___.
Definition
- 2
- large
- risk factor status, history of illness, and health measurements
- employers
- health maintenance organizations
Term
Mass screening is screening on a ___ scale of ___ population groups regardless of ___ ___.
Definition
- large
- total population
- regardless of risk status
Term
Selective screening screens ___ of the population at __ ___ for the disease. This is more ___and likely to __ more __ cases. Give example.
Definition
- subsets
- high risk
- more economical, yield more true cases
- screening high-risk persons for Tay-Sachs
Term
Evaluation of a screening program:
Definition
Is there direct evidence that screening reduces morbidity and/or mortality?
What is the prevalence of disease in the target group? Can a high-risk group be reliably identified?
Can the screening test accurately detect the target condition?
(a) What are the sensitivity and specificity of the
test?
(b) Is there significant variation between examiners
in how the test is performed?
(c) In actual screening programs, how much earlier
are patients identified and treated?
Does treatment reduce the incidence of the intermediate outcome?
(a) Does treatment work under ideal, clinical trial
conditions?
(b) How do the efficacy and effectiveness of treatments
compare in community settings?
Does treatment improve health outcomes for people diagnosed clinically?
(a) How similar are people diagnosed clinically to those
diagnosed by screening?
(b) Are there reasons to expect people detected by
screening to have even better health outcomes than
those diagnosed clinically?
Is the intermediate outcome reliably associated with reduced morbidity and/or mortality?
Does screening result in adverse effects?
(a) Is the test acceptable to patients?
(b) What are the potential harms, and how often do they occur?
Does treatment result in adverse effects?
Term
selection bias:
Definition
Persons who participate in screening programs may be different from those who do not.
Term
Lead-time bias:
Definition
Screening test advances time of diagnosis
by detecting disease before onset of symptoms but does not affect the natural history and survival from the disease

Lead Time: amount of time by which diagnosis is advanced
Term
Can correct for lead time (y) by comparing survival for X years in the screened group with that for X – y years in the unscreened group.

Can also compare age-specific death rates in screened versus unscreened, instead of survival time from date of detection to death
Definition
Term
Length time bias:
Definition
Slower-progressing diseases with longer preclinical periods are more likely to be detected by screening than those diseases with shorter preclinical stage leading to an increase in the number of cases diagnosed at an early stage

May observe a favorable mortality in the screened group not because of the benefit of screening, but simply because of the over-representation of cases with better prognosis associated with long-preclinical disease.
Term
A subset of the length time bias is the overdiagnosis bias, explain:
Definition
extreme example of length bias that occur when
diseases with slow- or non-progression are
screen-detected (e.g., prostate cancer)
Term
types of controlled observational studies:
Definition
- cross-sectional
- case-controlled
- cohort
Term
experimental study design:
Definition
- randomized controlled trial
Term
Randomized trials are the design of choice for the evaluation of screening procedures

Provides a rigorous experimental evaluation

Randomized trials are often difficult to conduct because of ethical and logistic reasons
Definition
Term
RCT for screening require:
Definition
- large sample size
- high cost
- long follow-up period
Term
RCT is not ideal for:
Definition
- rare diseases
- when a test becomes widely used before a RCT is conducted
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