Diagnostic Reasoning 1

STUDENT SHEET

Performance of tests that are based on a positive/negative result

(dichotomous tests)

EXAMPLE 1: Evaluating a new diagnostic test

I wish to evaluate two published tests for appendicitis in patients presenting with abdominal
pain. I correlate the test results with the diagnosis of appendicitis which was defined by
abnormal findings at the time of surgery: this is then the reference /gold standard.

Test one was trialled in an A&E department and gave the following results:

Appendicitis (at time of surgery)

Present Absent

Test 1 Positive 36 12

result Negative 4 48

Test two was trialled in General Practice and gave the following results:

Appendicitis (at time of surgery)

Present Absent

Test 2 Positive 9 18

result Negative 1 72

a) Work out the following characteristics for each test:

Test one Test two

Detection rate / sensitivity

False positive rate

Specificity

Positive predictive value

b) What conclusions would you draw about the value of these two tests?
(write in your own words an interpretation for each measure)

1
c) Now calculate the positive likelihood ratio and positive predictive value
Positive likelihood ratio

(interpret the meaning of the positive likelihood ratio)

Performance of tests that are based on the level of a marker /

measure (quantitative tests)

EXAMPLE 2. What is Normality?

Assume that there are 200 students in a lecture theatre and all are healthy.
I measure their serum sodium levels. How is the normal range defined?
How many would fall outside this normal range?

If I then do five other (unrelated) tests on each student. How many would fall within the
normal range on all 6 tests?

EXAMPLE 3: Is it sensible to screen for coronary heart disease (CHD) by measuring

serum cholesterol?

The measures of cholesterol were made some years previously, i.e. before men died of
CHD.

Group Mean serum total cholesterol (standard

deviation)
In Men who did not die of CHD 6.2 mmol/l (1.16 mmol/l)
In Men who did die of CHD 6.7 mmol/l (1.34 mmol/l)

This data are shown graphically as histograms below

Men who did not die of CHD Men who died of CHD

.1
.1
proportion

proportion

.05 .05

0 0
2 3 4 5 6 7 8 9 10 11 12 2 3 4 5 6 7 8 9 10 11 12
Serum cholesterol mmol/l Serum cholesterol mmol/l

Figure 1. Histogram of cholesterol values in men who did not died from CHD and in men that
died from CHD

a) Determine the 95% central range of the data in these two groups of men. Please use
1.96 as the multiplier rather than 2.

2
b) What do these ranges tell you about the distribution of cholesterol in middle aged men?

c) What proportion of men who do not die of CHD are expected to have values above
8.5mmol/l?

d) What proportion of men who die of CHD are expected to have values below 4.1mmol/l?

5. Determine the 90% reference range for men who dont die from CHD and 70%
references ranges for men who die from CHD given the following definitions for these
reference ranges

90% central range is defined by Mean 1.64 x standard deviation

70% central range is defined by Mean 1.03 x standard deviation

Using the information given above, what is the cut-off for serum cholesterol such that the
false positive rate is 5% i.e. 5% of men who do not die of CHD are expected to have values
above this cut-off?

How many men who die of CHD are expected to have values above this cut-off?

References
1. EDUCATION AND DEBATE: N J Wald, A K Hackshaw, and C D Frost. When can a risk
factor be used as a worthwhile screening test? BMJ, Dec 1999; 319: 1562 1565