1/20/2019 Introduction to ROC curves

Introduction to ROC Curves

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The sensitivity and specificity of a diagnostic test

depends on more than just the "quality" of the test--
they also depend on the definition of what constitutes
an abnormal test.  Look at the the idealized graph at
right showing the number of patients with and without
a disease arranged according to the value of a
diagnostic test. This distributions overlap--the test (like
most) does not distinguish normal from disease with
100% accuracy. The area of overlap indicates where
the test cannot distinguish normal from disease. In
practice, we choose a cutpoint (indicated by the vertical
black line) above which we consider the test to be
abnormal and below which we consider the test to be
normal. The position of the cutpoint will determine the
number of true positive, true negatives, false positives
and false negatives. We may wish to use different
cutpoints for different clinical situations if we wish to
minimize one of the erroneous types of test results.

We can use the hypothyroidism data from the likelihood ratio section to illustrate how sensitivity and
specificity change depending on the choice of T4 level that defines hypothyroidism. Recall the data on
patients with suspected hypothyroidism reported by Goldstein and Mushlin (J Gen Intern Med
1987;2:20-24.). The data on T4 values in hypothyroid and euthyroid patients are shown graphically
(below left) and in a simplified tabular form (below right).
T4 value Hypothyroid Euthyroid
5 or less 18 1
5.1 - 7 7 17
7.1 - 9 4 36
9 or more 3 39
Totals: 32 93

Suppose that patients with T4 values of 5 or less are considered to be hypothyroid.  The data display
then reduces to:
 
T4 value Hypothyroid Euthyroid
5 or less 18 1
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1/20/2019 Introduction to ROC curves

>5 14 92
Totals: 32 93
You should be able to verify that the sensivity is 0.56 and the specificity is 0.99.

Now, suppose we decide to make the definition of hypothyroidism less stringent and now consider
patients with T4 values of 7 or less to be hypothyroid.  The data display will now look like this:
 
T4 value Hypothyroid Euthyroid
7 or less 25 18
>7 7 75
Totals: 32 93
You should be able to verify that the sensivity is 0.78 and the specificity is 0.81.
 
 Lets move the cut point for hypothyroidism one more time:
T4 value Hypothyroid Euthyroid
<9 29 54
9 or more 3 39
Totals: 32 93
You should be able to verify that the sensivity is 0.91 and the specificity is 0.42.
 
Now, take the sensitivity and specificity values above and put them into a table:
Cutpoint Sensitivity Specificity
5 0.56 0.99
7 0.78 0.81
9 0.91 0.42
Notice that you can improve the sensitivity by moving to cutpoint to a higher T4 value--that is, you
can make the criterion for a positive test less strict.  You can improve the specificity by moving the
cutpoint to a lower T4 value--that is, you can make the criterion for a positive test more strict.  Thus,
there is a tradeoff between sensitivity and specificity. You can change the definition of a positive test to
improve one but the other will decline.

The next section covers how to use the numbers we just calculated to draw and interpret an ROC
curve.
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