Diagnostic

test
Magdalena
Sidhartani
 Terms
Sensitivity: probability that test or
procedure result will be positive when the
disease is present
Specificity: probability that the test or
procedure result will be negative when
the disease is not present
Positive predictive value: probability
that the disease is present when the test
or procedure is positive
 Terms
Cutoff point: the arbitrary value
used to separate positive from
negative result for any given test or
procedure.
Receiver operating characteristic
(ROC) curve: a graphic plot of true
versus false positive test result at
various cutoff points.
LR: expresses the odds that a given
level of a diagnostic test result
would be expected in a patient with
the target disease.
 Purposes of test
I. Diagnosis of disease
II. Screening
III. Management

I. Diagnosis of disease
1. To establish diagnosis by ruling out specific
diseases. It requires very sensitive test.
When normal, we exclude the disease
2. Pursuit strong clinical suspicion. It requires
very specific test.
When abnormal, confirm the presence of disease
 Purposes of test
II. Screening
Purpose of screening asymptomatic
patients:
Detect diseases whose morbidity and
mortality can be reduce by early
detection and treatment
Guidelines for selection of test:
The disease should be common.
Has significant morbidity if not
treated
 Purposes of test
III. Management
To monitor the status of disease
(progression, stable, resolution?)
To identify and reverse complication of
th/ (drug toxicity)
To ensure therapeutic levels of drugs
To aid in prognosis
To check an unexpected test result

reproducibility is important
 How to Choose ?
High sensitivity:
Important penalty for missing a disease
(dangerous but treatable: TBC, syphilis,
Hodgkin)
Early stages of diagnostic work-up
To role out disease
Probability of disease is low
To discover disease: screen people
without complaints
High specificity:
To confirm disease
Needed if false positive result will harm
the patient: physically, emotionally,
financial (chemotherapy)
 Trade off ?
Ordinal data Gold standard
+ -
Test ++++ 40 2
+++ 25 4
++ 15 6
+ 10 8
- 10 80
100 100
 Trade off ?
1. If ++++
Sensitivity: 40/100 = 40%
Specificity: (100-2)/100=98%
2. if +++
Sensitivity: (40+25)/100 = 65%
Specificity: [100-(2+4)]/100=94%
3. if ++
Sensitivity: (40+25+15)/100 =
80%
ROC

a graphical
plot of the
sensitivity vs.
(1 - specificity)
for a
binary classifie
r
system
 ROC
Provides tools to select optimal
models.
Discard suboptimal ones
independently from (and prior to
specifying) the cost context or class
distribution.
Cost/Benefit analysis of diagnostic
decision making. Widely used in
medicine, radiology, psychology
and other areas.
ROC
 The intercept of the ROC curve
with the line at 90 degrees to
the no-discrimination line
The area between the ROC
curve and the no-discrimination
line
The area under the ROC curve,
often called AUC.
 ROC
d' (pronounced "d-prime"), the
distance between the mean of the
distribution of activity in the system
under noise-alone conditions and its
distribution under signal plus noise
conditions, divided by their
standard deviation, under the
assumption that both these
distributions are normal with the
same standard deviation. Under
 AUC
The area under the ROC curve is
equivalent to the Mann-Whitney U
(tests for the median difference
between scores obtained in the two
groups if the groups are of
continuous data).
 Evaluation of
diagnostic test
1. Was there an independent, blind
comparison with a gold standard
2. did the sample include an
appropriate spectrum of mild,
severe, treated & untreated disease,
& individual with different but
commonly confused disorders
3. was the setting adequately
described
4. was the reproducibility of the rest
 Evaluation of
diagnostic test
5. was the term normal defined
sensibly
6. if the test advocated as part of
a sequence of tests, was its
contribution to the overall
validity of the sequence
determined
7. were the procedures for
carrying cut the test described
in sufficient detail to permit