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Diagnostic Tests
Payam Kabiri, MD. PhD.
Clinical Epidemiologist
Tehran University of Medical Sciences
Seven question to evaluate the
utility of a diagnostic test
Can the test be reliably performed?
Was the test evaluated on an appropriate
population?
Was an appropriate gold standard used?
Was an appropriate cut-off value chosen
to optimize sensitivity and specificity?
Seven question to evaluate the
utility of a diagnostic test
What are the positive and negative
likelihood ratios?
How well does the test perform in specific
populations?
What is the balance between cost of the
disease and cost of the test?
Which one of these test is the best
for SLE Dx?
Test Sensitivity% Specificity%
ANA 99 80
dsDNA 70 95
ssDNA 80 50
Histone 30-80 50
Nucleoprotein 58 50
Sm 25 99
RNP 50 87-94
PCNA 5 95
Diagnostic Tests Characteristics
Sensitivity
Specificity
PredictiveValue
Likelihood Ratio
5
Validity of Screening Tests
True Disease Status
Results of + -
Screening Test
+ a b
- c d
Sensitivity = a / (a + c)
6
Validity of Screening Tests
True Disease Status
Results of + -
Screening Test
+ a b
- c d
Specificity = d / (b + d)
7
Two-by-two tables can also be used for
calculating the false positive and false
negative rates.
The false positive rate = false positives /
(false positives + true negatives). It is also
equal to 1- specificity.
The false negative rate = false negatives /
(false negatives + true positives). It is also
equal to 1 – sensitivity.
An ideal test maximizes both sensitivity
and specificity, thereby minimizing the
false positive and false negative rates.
Validity of Screening Tests
Breast Cancer
Physical Exam + -
and Mammo-
graphy + 132 983
- 45 63650
Sensitivity: a / (a + c)
Sensitivity =
Specificity: d / (b + d)
Specificity =
10
Validity of Screening Tests
Breast Cancer
Physical Exam + -
and Mammo-
graphy + 132 983
- 45 63650
Sensitivity: a / (a + c)
Sensitivity = 132 / (132 + 45) = 74.6%
Specificity: d / (b + d)
Specificity = 63650 / (983 + 63650) = 98.5%
11
2 X 2 table
Disease
+ -
Positive
+
predictive
Test value
Sensitivity
Natural Frequencies Tree
Population
100
In Every 100 People, 4 Will Have The Disease
Population
100
Disease + Disease -
4 96
Population
100
Disease + Disease -
4 96
Disease + Disease -
4 96
Disease + Disease -
4 96
Test - Test -
1 89
AMONG THOSE WHO TEST NEGATIVE, 89 OF 90 WILL
NOT HAVE THE DISEASE
Population
100
Disease + Disease -
4 96
Test + Test +
3 7
Population
100
Disease + Disease -
4 96
Test + Test +
3 7
Test - Test -
1 89
PREDICTIVE VALUES AND CHANGING PREVALENCE
Population
1000
Disease + Disease -
4 996
Disease + Disease -
4 996
Test + Test +
3 70
Test - Test -
1 926
POSITIVE PREDICTIVE VALUE AT LOW PREVALENCE
Population
Previously, PPV
1000
was 30%
Disease + Disease -
4 996
Test - Test -
1 926
NEGATIVE PREDICTIVE VALUE AT LOW PREVALENCE
Population
Previously, NPV
1000
was 99%
Disease + Disease -
4 996
Test + Test +
3 70
0.8
relatively small
0.6
0.4
Difference between
0.2 PPV PPV and NPV
relatively large
NPV
0
0.05 0.2 0.4 0.6 0.8 0.95
Pre-test Probability (Prevalence)
Prevalence
LR+ = 9.0
B : Sensitivity =
Specificity = 0.7
LR+ = 3.0
C : Sensitivity =
Specificity = 0.5
LR+ = 1.0
2 X 2 table
Sensitivity
FALSE
NEGATIVES
Sensitivity
The proportion of people with the diagnosis (N=4) who are
correctly identified (N=3)
Sensitivity = a/(a+c) = 3/4 = 75%
Specificity
FALSE
POSITIVES
Specificity
The proportion of people without the diagnosis (N=96) who
are correctly identified (N=89)
Specificity = d/(b+d) = 89/96 = 93%
Value of a diagnostic test depends
on the prior probability of disease
Prevalence Prevalence
(Probability) = 5% (Probability) = 90%
Sensitivity = 90% Sensitivity = 90%
Specificity = 85% Specificity = 85%
PV+ = 24% PV+ = 98%
PV- = 99% PV- = 49%
Test not as useful
when disease unlikely
Test not as useful
when disease likely
31
A Test With Normally
Distributed Values
Assessing the performance of
Test cut-off the test assumes that these
two distributions remain
constant. However, each of
them will vary (particularly
through spectrum or selection
bias)
% of Group
NON-DESEASED
DISEASED
Negative Positive
Degree of ‘positivity’ on test
Performance of A Diagnostic
Test
NON-CASES CASES
FALSE
NEGATIVES Test cut-off
FALSE
POSITIVES
% of Group
NON-DESEASED
DISEASED
Negative Positive
Degree of ‘positivity’ on test
Minimising False Negatives: A
Sensitive Test
NON-CASES CASES
Cut-off shifted to minimise
Test cut-off false negatives ie to
optimise sensitivity
CONSEQUENCES:
- Specificity reduced
% of Group
Negative Positive
Degree of ‘positivity’ on test
Minimising False Positives: A
Specific Test
Cut-off shifted to
minimise false positives
Test cut-off ie to optimise specificity
CONSEQUENCES:
- Sensitivity reduced
% of Group
DISEASED
Negative Positive
Degree of ‘positivity’ on test
Receiver Operating Characteristics (ROC)
Non-diseased Diseased
Threshold
Threshold
Non-diseased Diseased
Centers Centers
Cutoff point
more typically:
Non-diseased Diseased
cases cases
FP rate
more typically:
Non-diseased Diseased
Centers Centers
TP rate
Non-diseased
Centers
TPF, sensitivity
Threshold
less aggressive
mindset
Diseased
Centers
FPF, 1-specificity
Non-diseased
cases
TPF, sensitivity
moderate
mindset
Threshold
Diseased
cases
FPF, 1-specificity
Non-diseased
cases
more
TPF, sensitivity
aggressive
mindset
Threshold
Diseased
cases
FPF, 1-specificity
Non-diseased
cases
Entire ROC curve
TPF, sensitivity
Threshold
Diseased
cases
FPF, 1-specificity
Entire ROC curve
e
il n
TPF, sensitivity
c e
an
ch
FPF, 1-specificity
Check this out:
http://www.anaesthetist.com/mnm/stats/ro
c/Findex.htm
Likelihood Ratios
Pre-test & post-test probability
Pre-test probability of disease can be
compared with the estimated later probability
of disease using the information provided by
a diagnostic test.
The difference between the previous
probability and the later probability is an
effective way to analyze the efficiency of a
diagnostic method.
It tells you how much a positive or negative
result changes the likelihood that a patient
would have the disease.
The likelihood ratio incorporates both the
sensitivity and specificity of the test and
provides a direct estimate of how much a test
result will change the odds of having a
disease
The likelihood ratio for a positive result
(LR+) tells you how much the odds of the
disease increase when a test is positive.
52
Positive Likelihood Ratios
This ratio divides the probability that a
diseased patient will test positive by the
probability that a healthy patient will test
positive.
The positive likelihood ratio
+LR = sensitivity/(1 – specificity)
False Positive Rate
The false positive rate = false positives /
(false positives + true negatives). It is also
equal to 1- specificity.
The false negative rate = false negatives /
(false negatives + true positives). It is also
equal to 1 – sensitivity.
Positive Likelihood Ratios
It can also be written as the
true positive rate/false positive rate.
Thus, the higher the positive likelihood
ratio, the better the test (a perfect test has
a positive likelihood ratio equal to infinity).
Negative Likelihood Ratio
This ratio divides the probability that a
diseased patient will test negative by the
probability that a healthy patient will test
negative.
The negative likelihood ratio
–LR = (1 – sensitivity)/specificity.
False Negative Rate
The false negative rate = false negatives /
(false negatives + true positives).
It is also equal to 1 – sensitivity.
Negative Likelihood Ratio
It can also be written as the
false negative rate/true negative rate.
Therefore, the lower the negative
likelihood ratio, the better the test (a
perfect test has a negative likelihood ratio
of zero).
Positive & Negative Likelihood
Ratios
Post-test Odds =
Likelihood Ratio X Pre-test Odds
Using Likelihood Ratios to Determine Post-
Test Disease Probability
Pre-test Pre-test
probability odds of
of disease disease Post-test Post-test
odds of probability
disease of disease
Likelihood
ratio
62
Pre-test & post-test probability
“Post-test probability” depends on the
accuracy of the diagnostic test and the
pre-test probability of disease
A test result cannot be interpreted without
some knowledge of the pre-test probability
Where does “pre-test
probability” come from?
Clinical experience
Epidemiological data
“Clinical decision rules”
Guess
what is the likelihood that this
patient has the disease?
Sensitivity
1 – Specificity
= 0.88 / (1 – 0.82)
= 4.89
22 positive
Disease +ve 30 15 15
tests in
total of
which 15
100 have the
disease
Disease -ve
70 63 About 70%
70 – 63 = 7
Likelihood
Population
100
Disease +
4 The likelihood that
someone with the
disease will have a
Test +
positive test is ¾ or
3 75%
This is the same as
Test - the sensitivity
1
Likelihood II
Population
100
Disease -
96
The likelihood that
someone without
the disease will Test +
have a positive test 7
is 7/96 or 7%
This is the same as Test -
the (1-specificity)
89
Likelihood Ratio
Likelihood of Positive Test Given
The Disease
Likelihood Ratio =
Likelihood of Positive Test
in the Absence of the Disease
Sensitivity 0.75
= = = 10.7
1- Specificity 0.07
3
The Diagnostic Odds Ratio is DOR 7
1
the ratio of odds of having the 89
diagnosis given a positive test
0.429
38.2
to those of having the 0.011
77
What is this second fraction?
Likelihood Ratio Positive
Multiplied by any patient’s pretest odds
gives you their posttest odds.
Comparing LR+ of different tests is
comparing their ability to “rule in” a
diagnosis.
As specificity increases LR+ increases and
PPV increases (Sp P In)
78
Clinical interpretation of post-
test probability
Probability of disease:
Don't Do further
treat for diagnostic Treat for
disease testing disease
0 1
Testing Treatment
threshold threshold
If you are here, Test
will help you to go
Disease toward one end of
Disease
ruled out this probability,
ruled in
either 0 or 1 to get
79 the final decision.
Values of Positive and Negative
Likelihood Ratios (LR)
Positive
likelihood 2.1-5 5.1-10 10>
ratio
Negative
likelihood 0.5-0.2 0.19-0.1 0.1<
ratio
Likelihood Ratios & You
Allows us to determine the accuracy with which a
test identifies the target disorder
As the LR becomes larger, the likelihood of the
target disease increases:
Likelihood ratio Interpretation
>10 Strong evidence to rule in disease
5-10 Moderate evidence to rule in disease
2-5 Weak evidence to rule in disease
0.5-2 No significant change in the likelihood of disease
0.2-0.5 Weak evidence to rule out disease
0.1-0.2 Moderate evidence to rule out disease
<0.1 Strong evidence to rule out disease
Advantages of LRs
The higher or lower the LR, the higher or lower
the post-test disease probability
Which test will result in the highest post-test
probability in a given patient?
The test with the largest LR+
Which test will result in the lowest post-test
probability in a given patient?
The test with the smallest LR-
82
Advantages of LRs
Clear separation of test characteristics
from disease probability.
83
Likelihood Ratios - Advantage
Provide a measure of a test’s ability to rule
in or rule out disease independent of
disease probability
Test A LR+ > Test B LR+
Test A PV+ > Test B PV+ always!
Test A LR- < Test B LR-
Test A PV- > Test B PV- always!
84
Predictive Values
Alternate formulations:Bayes’ Theorem
PV+ =
Se Pre-test Prevalence
Se Pre-test Prevalence + (1 - Sp) (1 - Pre-test Prevalence)
PV- =
Sp (1 - Pre-test Prevalence)
Sp (1 - Pre-test Prevalence) + (1 - Se) Pre-test Prevalence
85
Clinical Interpretation: Predictive Values
F <40 32 88
F 40-50 46 80
F 50+ 62 68
M <40 62 68
M 40-50 75 54
M 50+ 85 38
86
If Predictive value is more
useful why not reported?
Should they report it?
Only if everyone is tested.
And even then.
You need sensitivity and specificity from
literature. Add YOUR OWN pretest
probability.
87
So how do you figure pretest
probability?
Start with disease prevalence.
Refine to local population.
Refine to population you serve.
Refine according to patient’s presentation.
Add in results of history and exam (clinical
suspicion).
Also consider your own threshold for testing.
88
Pretest Probability: Clinical
Significance
Expected test result means more than
unexpected.
Same clinical findings have different
meaning in different settings
(e.g.scheduled versus unscheduled visit).
Heart sound, tender area.
Neurosurgeon.
Lupus nephritis.
89
What proportion of all patients
will test positive?
Diseased X sensitivity
+ Healthy X (1-specificity)
Prevalence X sensitivity +
(1-prevalence)(1-specificity)
We call this “test prevalence”
i.e. prevalence according to the test.
Some Examples
Diabetes mellitus (type 2)
Check out this:
Some Examples from
Essential Evidence Plus
Disease Link Address
http://www.essentialevidenceplus.com/
Which one of these test is the best
for SLE Dx?
Test Sensitivity Specificity LR(+)
ANA 99 80 4.95
dsDNA 70 95 14
ssDNA 80 50 1.6
Histone 30-80 50 1.1
Nucleoprotein 58 50 1.16
Sm 25 99 25
RNP 50 87-94 3.8-8.3
PCNA 5 95 1
Was it clear enough !
Key References