Clinical tests: sensitivity andspeciﬁcity
Abdul Ghaaliq Lalkhen MB ChB FRCAAnthony McCluskey BSc MB ChB FRCA
Many clinical tests are used to conﬁrm orrefute the presence of a disease or further thediagnostic process. Ideally such tests correctlyidentify all patients with the disease, and simi-larly correctly identify all patients who aredisease free. In other words, a perfect test isnever positive in a patient who is disease freeand is never negative in a patient who is in factdiseased. Most clinical tests fall short of thisideal.
Sensitivity, speciﬁcity, andother terms
The following terms are fundamental to under-standing the utility of clinical tests:1.
: the patient has the disease andthe test is positive.2.
: the patient does not have thedisease but the test is positive.3.
: the patient does not have thedisease and the test is negative4.
: the patient has the diseasebut the test is negative.When evaluating a clinical test, the terms sen-sitivity and speciﬁcity are used. They are inde-pendent of the population of interest subjected tothe test. The terms positive predictive value(PPV) and negative predictive value (NPV) areused when considering the value of a test to aclinician and are dependent on the prevalence of the disease in the population of interest.
The sensitivity of a clinical test refers to theability of the test to correctly identify thosepatients with the disease.Sensitivity
True positivesTrue positives
False negativesA test with 100% sensitivity correctly ident-iﬁes all patients with the disease. A test with80% sensitivity detects 80% of patients withthe disease (true positives) but 20% with thedisease go undetected (false negatives). A highsensitivity is clearly important where the test isused to identify a serious but treatable disease(e.g. cervical cancer). Screening the femalepopulation by cervical smear testing is a sensi-tive test. However, it is not very speciﬁc and ahigh proportion of women with a positive cer-vical smear who go on to have a colposcopyare ultimately found to have no underlyingpathology.
The speciﬁcity of a clinical test refers to theability of the test to correctly identify thosepatients without the disease.Specificity
True negativesTrue negatives
False positivesTherefore, a test with 100% speciﬁcity cor-rectly identiﬁes all patients without the disease.A test with 80% speciﬁcity correctly reports80% of patients without the disease as testnegative (true negatives) but 20% patientswithout the disease are incorrectly identiﬁed astest positive (false positives).As discussed above, a test with a high sensi-tivity but low speciﬁcity results in manypatients who are disease free being told of thepossibility that they have the disease and arethen subject to further investigation. Althoughthe ideal (but unrealistic) situation is for a100% accurate test, a good alternative is tosubject patients who are initially positive to atest with high sensitivity/low speciﬁcity, to asecond test with low sensitivity/high speciﬁcity.In this way, nearly all of the false positivesmay be correctly identiﬁed as disease negative.
Positive predictive value
The PPV of a test is a proportion that is usefulto clinicians since it answers the question:‘How likely is it that this patient has the
Sensitivity and speciﬁcity areterms used to evaluate aclinical test. They areindependent of thepopulation of interestsubjected to the test.Positive and negativepredictive values are usefulwhen considering the valueof a test to a clinician. Theyare dependent on theprevalence of the disease inthe population of interest.The sensitivity and speciﬁcityof a quantitative test aredependent on the cut-off value above or below whichthe test is positive. Ingeneral, the higher thesensitivity, the lower thespeciﬁcity, and vice versa.Receiver operatorcharacteristic curves are aplot of false positives againsttrue positives for all cut-off values. The area under thecurve of a perfect test is 1.0and that of a useless test, nobetter than tossing a coin, is0.5.
Abdul Ghaaliq Lalkhen MB ChB FRCA
Specialist Registrar Salford Royal Hospitals NHS TrustHope HospitalSalford M6 8HDUK
Anthony McCluskey BSc MB ChB FRCA
ConsultantDepartment of AnaesthesiaStockport NHS Foundation TrustStepping Hill HospitalStockport SK2 7JEUK Tel: +44 (0161) 419 5869Fax: +44 (0161) 419 5045E-mail: firstname.lastname@example.org(for correspondence)
doi:10.1093/bjaceaccp/mkn041Continuing Education in Anaesthesia, Critical Care & Pain | Volume 8 Number 6 2008
The Board of Management and Trustees of the British Journal of Anaesthesia .All rights reserved. For Permissions, please email: email@example.com