404 LETTERS
unable to ‘‘comprehend overdose as
more than a pharmacologic event.’’
We are offended by the statement.
Our inner-city hospital sees a large
number of patients with addiction
problems and has a reputation for
compassionate care of these pa-
tients. This does not mean that we
can admit every person presenting
with addiction-related problems, nor
that we know the secrets to long-
term maintenance of harm reduc-
tion and abstinence. We have
opened beds in our ED specifically
related to addiction, psychiatric ill-
ness, and dual-diagnoses. We have a
24-hour social worker who assists
any patients wanting help beyond
the ED to connect with other social
agencies. We are working on a study
to identify strategies to overcome
the issues of undertreatment of pa-
tients with HIV, particularly in the
intravenous drug-using population.
We have community meetings with
social agencies, clinics, and primary
care physicians to identify how to
improve our care of inner-city pa-
tients, particularly those without
homes or those addicted to drugs
and alcohol. This study is only a
small piece of the overall under-
standing of these vexing problems,
but nevertheless, it is important to
understand the incidence of serious
complications of opioid overdose and
the predictors that determine
whether a patient is safe from the
pharmacologic consequences of this
overdose event. We believe that pre-
dicting future overdoses would be an
admirable goal but one that we did
not attempt to tackle.
Su and Hoffman justly state that
these patients often require other
support. We agree. After the over-
dose, heroin addicts need psycholog-
ical support, safe housing, counsel-
ing, detoxification, rehabilitation,
training, and reintegration into the
community. Someday, emergency
physicians may have the expertise
and resources to provide these im-
portant components of care. At pres-
ent, we do not, and these functions
do not occur in the ED. While they
are important, they are peripheral
to the study question. Our research
question was: Is it possible to iden-
tify patients who are safe (based on
medical, not sociological, outcome
measures) for early discharge after
opioid overdose? Contrary to what
Su and Hoffman suggest, our study
does not conclude that the only thing
a heroin addict needs is an injection
of naloxone. Our study merely iden-
tifies objective and reliable criteria
that tell us when it is reasonable to
refer the patient to our social worker
and turn the ED stretcher over to
the next patient in the waiting room.
We fully endorse the active interven-
tions in these areas once the medical
event is stabilized.
We hope that readers view our
study as one small component of the
care of opioid overdose patients. We
believe that it is usually unneces-
sary to monitor patients in an acute
care setting for recurrent apnea and
onset of adult respiratory distress
syndrome when they have normal
temperature, respiratory rate, oxy-
gen saturation, Glasgow Coma Scale
score, heart rate, and ability to mo-
bilize one hour after administration
of naloxone. Such information does
not preclude other appropriate med-
Reliability and Validity of Diagnostic Tests
Fridriksson et al. recently conducted
a pilot study assessing serum neu-
ron-specific enolase (NSE) as a pre-
dictor of intracranial leasions (ICL)
in children with head trauma.1 The
authors make an important error
describing the objectives of their
study. They note, ‘‘The objective of
our pilot study was to evaluate the
reliability of serum NSE in predict-
ing ICL identified on head CT in
children with acute blunt head
trauma.’’ However, the authors were
not assessing the ‘‘reliability’’ of this
diagnostic test. In fact, they were as-
sessing the test’s ‘‘validity.’’
Both reliability and validity are
measures of test performance, but
they have separate and distinct
meanings.2,3 Validity is the degree to
which the data measure what they
were intended to measure (i.e., ac-
curacy) when compared with a true
measure, otherwise know as a cri-
terion standard or ‘‘gold standard.’’
The term validity is also used when
referring to the ability of a test to
classify subjects into dichotomous
categories of diseased versus non-
diseased. In this situation, validity
is described in terms of sensitivity
CORRESPONDENCE
ical, social, and psychiatric interven-
tions.—JIM CHRISTENSON, MD
(jimchris@interchange.ubc.ca), JER-
EMY ETHERINGTON, MD, GRANT
INNES, MD, ERIC GRAFSTEIN, MD,
KAREN WANGER, MD, CHRIS FER-
NANDES, MD, JOHN J. SPINELLI,
PHD, MIN GAO, MD, PHD, and
SARAH PENNINGTON, RN, the St.
Paul’s Hospital Department of Emer-
gency Medicine, the Centre for
Health Evaluation and Outcome Sci-
ences, University of British Colum-
bia, Vancouver, BC, Canada
Key words. opioids; heroin; over-
dose; clinical prediction rule; dis-
charge; prediction.
Reference
1. Christenson J, Etherington J, Graf-
stein E, et al. Early discharge of patients
with presumed opioid overdose: devel-
opment of a clinical prediction rule. Acad
Emerg Med. 2000; 7:1110–8.
(i.e., the proportion of subject with
the disease who have a positive test)
and specificity (i.e., the proportion of
subjects without the disease who
have a negative test).
It is desirable for a diagnostic
test to be both highly sensitive and
highly specific. This is not usually
possible as increasing sensitivity de-
creases specificity, and vice versa.
Different testing strategies have dif-
ferent requirements for sensitivity
and specificity.3 Since highly sensi-
tive tests are rarely negative in the
presence of disease, these types of
tests are particularly useful during
early stages of a diagnostic workup
or when there is reason to suspect a
dangerous illness. Highly specific
tests are rarely positive in the ab-
sence of disease. Thus, these types of
tests are helpful for confirming a di-
agnosis that is suggested by clinical
data or other tests.
In contrast, reliability is the ex-
tent to which repeated measure-
ments get similar results (i.e., pre-
cision or reproducibility).2,3 It refers
to the capacity of a test to give the
same result on repeated application.
ACADEMIC EMERGENCY MEDICINE • April 2001, Volume 8, Number 4
Reliability depends on 1) the varia-
bility in the specific manifestation
on which the test is based, 2) the
variability in the method of mea-
surement, and 3) the skill with
which the measurement is made.
One measure of reliability, for ex-
ample, would be the degree of dis-
persal of repeated measurements
characterized as variance or stan-
dard deviation. While reliability
does not imply nor guarantee valid-
ity (i.e., high sensitivity and specific-
ity), unreliability will probably make
a test insufficiently sensitive or spe-
cific to be valid.2
Confusion between validity and
reliability, as with many clinical ep-
idemiology terms, is very common.
Nevertheless, inaccurate use should
be avoided whenever possible as it
clouds important distinctions of con-
cepts concerning clinical research
and medical decision making that
are crucial for veracious discourse
among clinicians. — DEMETRIOS N.
KYRIACOU, MD, PHD, Division of
Emergency Medicine, Northwestern
University Medical School, Chicago,
IL
405
Key words. reliability; validity; di-
agnostic tests; sensitivity; specificity.
References
1. Fridriksson T, Kini N, Walsh-Kelly C,
Hennes H. Sterum neuron-specific eno-
lase as a predictor of intracranial lesions
in children with head trauma: a pilot
study [brief report]. Acad Emerg Med.
2000; 7:816–20.
2. Morrison AS. Screening. In: Rothman
KJ, Greenland S (eds). Modern Epide-
miology, 2nd ed. Philadelphia: Lippin-
cott-Raven, 1998.
3. Fletcher RH, Fletcher SW, Wagner
EH. Clinical Epidemiology, 3rd ed. Bal-
timore: Williams & Wilkins, 1996.