Evaluasi Skrining

Kesehatan
Atik Choirul Hidajah
Maznah Dahlui
skrining salah satu upaya pencegahan
 Myth:
Early detection is good for everyone

• Kadang-kadang seseorang secara reguler melakukan pemeriksaan kesehatan meskipun

tidak memiliki gejala apa pun, karena mereka beranggapan dokter mungkin menemukan
sesuatu dengan pengetahuan dan teknologi khusus yang memungkinkan "deteksi dini"
penyakit.
• Dokter dan perusahaan sering mendorong skrining pada orang yang tampaknya sehat,
dengan keyakinan itu adalah tindakan yang baik.
• Benarkah??
When should we screen?
Screen when:
• It is an important health problem (think about how to define
‘important’?)
• There is an accepted and effective treatment
• Disease has a recognizable latent or early symptomatic stage
• There are adequate facilities for diagnosis and treatment
• There is an accurate screening test
• There is agreement as whom to consider as cases
 Evaluasi alat/instrumen
Evaluasi
Skrining
Kesehatan
Evaluasi program skrining
Logic of Screening
Apparently well population

Screening test

Negative results Positive results

Disease No disease Disease No disease

(False negative) (True negative) (True positive) (False positive)
• Banyak tes yang digunakan tidak terlalu akurat  perlu dinilai
validitasnya
• Menemukan kondisi sakit namun tidak ada pengobatan yang efektif
 tidak etis
 Evaluasi
Alat
Skrining

Validitas Reliabilitas

Akurasi Intra Inter

Sensitivitas Spesifisitas Intra Subjek
Prediksi Observer Observer

PPV NPV
Evaluating Screening Programs
• Efektivitas program skrining pada akhirnya diukur dari kemampuannya
untuk mengurangi morbiditas dan mortalitas penyakit.
• Ukuran efikasi yang paling definitif adalah terdapat perbedaan dalam
cause spesific mortality rate antara mereka yang ditemukan dengan
skrining versus mereka yang didiagnosis jika gejala sudah muncul 
dinilai dengan penelitian epidemiologi
Studi Korelasional
• Menilai trend cause spesific mortality rate karena suatu penyakit dari
waktu ke waktu dan menghubungkannya dengan frekuensi skrining
dalam suatu populasi.
• Kelemahan:
1. Ukuran untuk seluruh populasi, dan tidak dapat menentukan bahwa
penurunan mortalitas terjadi di antara mereka yang diskrining;
2. Tidak dapat memperhitungkan faktor perancu;
3. Tidak dapat menentukan strategi skrining yang optimal untuk populasi
sesuai dengan karakteristiknya.
Kasus Kontrol dan Kohor
• Studi kasus-kontrol dan kohor sering digunakan untuk mengevaluasi
skrining,
• Keterbatasan utamanya adalah bahwa kelompok penelitian mungkin
tidak sebanding karena:
• faktor confounders,
• volunteer bias,
• lead-time bias, and
• length-time bias.
Randomized Clinical Trial
• Cara optimal mengevaluasi keberhasilan program skrining adalah
dengan melakukan uji klinis acak (RCT) dengan sampel yang cukup
besar untuk memastikan kontrol faktor perancu potensial.
• Keterbatasan:
• Masalah biaya dan etika yang terkait dengan RCT untuk skrining dapat
menjadi substansial, dan
• Banyak data yang berasal dari studi observasional.
• Beberapa hal yang dapat mempengaruhi efektivitas program
skrining:
• Self selection bias
• Lead-time bias
• Length time bias
Self Selection Bias
• Orang yang memilih untuk berpartisipasi dalam program skrining
cenderung lebih sehat, memiliki gaya hidup yang lebih sehat, dan
mereka cenderung mengikuti terapi dengan lebih baik, sehingga hasil
cenderung lebih baik karena ini.
• Namun, relawan juga dapat mewakili kelompok yang memiliki
kekhawatiran yang baik (worried well) yaitu orang yang tidak
menunjukkan gejala, tetapi mempunyai risiko yang lebih tinggi
(misalnya, kerabat wanita dengan kanker payudara).
Lead-time bias
• Skrining memungkinkan penyakit lebih dini teridentifikasi, sehingga
pengobatan dapat dilakukan pada tahap awal  efek penyembuhan
atau setidaknya kelangsungan hidup yang lebih lama.
• Skrining dapat memberi lompatan pada penyakit; adanya “lead-time"
adalah hal yang baik, tetapi dapat bias untuk menunjukkan efektivitas
skrining.
Length time bias

• Panjang survival rate dapat bervariasi dari orang ke orang.

• Misalnya, Kanker prostat adalah tumor yang tumbuh sangat lambat
pada banyak pria, tetapi sangat cepat berkembang dan mematikan
pada orang lain.
• Perbedaan-perbedaan dalam survival rate ini membesar-besarkan
manfaat nyata dari skrining, karena ada kemungkinan bahwa skrining
akan mendeteksi subjek dengan survival rate panjang, padahal
penyakit tersebut lebih jinak.
Evaluation 1) Importance of health program
evaluation
Health 2) Principles of economic evaluation as a
Screening tool for resource allocation
3) Examples of health screening
Program evaluation
 Program
Development
Program Development
Steps in coming up with a program

Health Issues
1. An intervention or a program is developed to
overcome identified health issues
2. A program must first decide on its objective(s)
3. Subsequently, a plan on how to meet the Objective
objective(s) would be developed
4. The plan consists of the activities that can help
meet the objective(s)
Evaluation Planning
5. Upon implementation, we need to determine
whether the objective(s) is met
6. Evaluation is actually performed at various steps
7. Data is needed at every steps Implementation
Program Evaluation
 Evaluation of interventions (program/project/policy) is performed
for various reasons;

To measure the effectiveness of the intervention

Evaluation of To determine the feasibility of implementation

Health To assess the acceptance and accessibility by the targeted group

Interventions
- purpose To know the cost implications

To determine whether the program is sustainable

To decide on which intervention among several interventions with

the same objective would give the highest return of investment
 • Insight – on the needs, barriers and activities
• Improvement
• Social mobilization
Uses of • Inter-sectoral coordination
Health • Implementation
• Client conveniences
Program • Outcome/impact
Evaluation • Skill development
• Behavioral change
• Level of success in achieving objectives
• accountability
Types of Evaluation

• Formative
• Summative These are sequential and built
on each other (cannot do
• Outcome impact evaluation without
• Impact evidence of positive outcome)
• Economic
 Measures overall effectiveness
of the program based on the
set specific objectives
Outcome
evaluation - the number of cases detected
- the % of people with behavior
Example: change
- the reduction in incidences of
diseases
Impact evaluation Economic evaluation
• Compare program with similar • Measures a longer term program
long term impact to determine impact in target population
which one is more cost effective
Measurement of Effectiveness
• Starts with setting the objective of intervention
• Followed by selection of indicators to determine whether the objective is met
• Example: To increase survival with better QoL of liver cancer patients due to hepatitis C infection

Program identified : Screening and treatment of Hep C patients

Indicators : Ab + Hep C with positive RNA treated with DAA

 Example : To prevent death from complications of Diabetes Mellitus

 Program identified : regular health check ups

 Indicators : measurement of blood glucose and HbA levels
 Feasibility of program
• Need to know whether a planned intervention is
practical
• In terms of resources – on its availability, provision
and sustainability
• Example ;
 procedure of implementation : what are the
obstacles?, customer’s satisfaction
 human resource : is the required expertise
available, do we need to train and how many?
 financial aspect : can the people afford?, Is
investment in capital needed or just operating
budget?.
 study methods : qualitative (observation, IDI),
surveys, data compilation, budget impact
analysis
Acceptance and Accessibility
Health interventions should be
developed in consideration of the wants
of the targeted population besides to
meet their health needs.
Example to introduce a community
screening program;
first need to determine which population would benefits
more (certain age, gender, locality and characteristics
(betel chewing population)
is the intervention culturally accepted (I.e PAP smear)
can the people afford the registration fee or transport to
the health facilities
 Economic
Evaluation
Economic evaluation is performed ….
To know the cost implications
To decide on which intervention among
several interventions with the same objective
is most cost-effective and provide the highest
return
To determine whether the program is worth
invested in
To ensure that the program could be sustained
 Money

Resources needed
for Healthcare
Man Man Material
Money
Materials
Facilities
Minutes (Time)
Management (System)

Health Program

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Budget is limited, and because of
that we have to make the right
decision on spending for healthcare.

Doctors are tight up when comes to providing

the best treatment to patients especially if the
drug is expensive.

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 Economic Evaluation
EE is not about comparing But to determine which intervention among
the cost and benefit of a several interventions with the same goal is
program, more cost-effective.

Program A

Cost Program B

Cost versus Benefits Looking for the more cost-effective

intervention
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Examples of Assessing Effectiveness of
Health Interventions

33
Evaluating the cost-
effectiveness of
cervical screening

 Pilot project for organized cervical

cancer screening (2012)

 all women aged 20 years old and

above were invited for PAP smear and
received recall to repeat the test.

 A CEA was conducted to determine

which recall method would be most
cost-effective.

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 Calling women for PAP smear via telephone was
the most cost-effective method.

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 Breast Cancer
Screening
Program

 Several studies had been

conducted locally on the
KAP of screening for breast
cancer among women in
Malaysia.

 KAP on breast cancer and

its screening uptake differ
across populations.

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 Breast Cancer
Screening
Program

 We need to know which

population needs more
intervention and

 Whether the current

practice is still relevant or
need to change.

 A cross sectional study

was conducted to assess
the situation.

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 Breast Cancer Screening program

 Breast Self Examination

(BSE) as screening for
breast cancer and Clinical
Breast Examination (CBE)
are still relevant in Malaysia,
where resources are limited.
 Question on whether we
should follow the practice of
mammogram as a national
community screening for
breast cancer as in
developed countries.
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 Implications of study findings
CEA of Breast Cancer Screening

Mammogram as a community breast cancer screening is not cost-

effective…
An economic evaluation had
been conducted to determine
the cost
The of various
current breast
practice of CBE followed by mammography when
cancer screening types in
abnormality is detected, and mammogram of women with risk
Malaysia.
factors are cost-effective according to the threshold set by MAHTA
(1 Whether
 GDP peritscapita)
worth for MOH to
provide mammogram as a
Recommendation:
community screeningefforts should be focused on improving the
for breast
participation
cancer. rate for CBE and increasing the budget allocation
for mammogram for the current BC screening program.

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Conclusion
• Evaluation should be in place when planning to set
up a health intervention program.
• Evaluation of program – for effectiveness, efficiency
and equity.
• Selection of the appropriate method for health
screening determines the cost-effectiveness of the
screening program – depends on the disease type
and population involved.
• For most health interventions, the benefits could
not be seen immediately (long term impact - return
of investment)
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