APPRAISING AN ARTICLE ON DIAGNOSTIC TESTS
DIRECTNESS
Does the study provide a direct
enough answer to your clinical
question in terms of patients (P),
exposure (E) and outcome (O)? In
this situation the exposure is the
test that is being evaluated, and the
outcome is the disease being
diagnosed
VALIDITY
Was the reference standard an
acceptable one?
Was the “definition” of the index
test and the reference standard
independent?
Was the “performance” of the index
test and the reference standard
independent?
Was the “interpretation” of the index
test and the reference standard
independent?
RESULTS
What were the likelihood ratios of
the various test results?
APPLICABILITY
Are there biologic issues that may
affect applicability of the estimates
of test accuracy? (Consider the
influence of sex, co-morbidity, race,
age and pathology)
Are there socio-economic issues
that may affect applicability of the
estimates of test accuracy?
INDIVIDUALIZING RESULTS
How might the test results affect
the probability of disease in your
individual patient?
Why is it Important
Many times, the P, E and O are not
exactly the same as those studied by
the authors of a paper. If this is the
case, you need to decide if you can
use the study results at all. The
decision requires some expertise on
the disease under question.
Why is it Important
The reference standard should be
one accepted by the scientific
community as the definition of
disease. It is the yardstick with which
the performance of the test is
measured.
If multiple criteria were used as
reference standard, the index test
should not be part of the criteria as
this will lead to a high level of
agreement between the two.
If the reference standard was done
because of a result of the index test,
then the index test will look better
than it actually is.
Knowledge of the results of an index
test may influence the interpretation
of results of the reference standard.
Why is it Important
Likelihood ratios tell us by how much
the likelihood of disease changes,
given a test result. It is a measure of
how useful a test is.
Why is it Important
Sometimes, these variables may
affect how well the test performs in
various populations.
Social, cultural and economic context
may potentially affect diagnostic test
performance.
Why it is important
Studies report average effects but
the effect on your patient may not
be average,
What to Look For
Seek the opinion of an expert (this
might be you), or your colleagues.
What to Look For
Look for how authors define presence
or absence of disease in the study
population.
Look at the criteria used to interpret
both reference and index text and
make sure they don’t overlap.
Look for measures taken to ensure
that the result of the index test did not
influence doing the reference
standard.
Look for measures to ensure that the
interpretation of the index test result
did not affect the interpretation of the
reference standard.
What to Look For
Look for likelihood ratios. If these are
not reported, they can be derived from
sensitivity and specificity.
What to Look For
Prior knowledge and experience with
the disease will be useful.
Prior knowledge and experience with
the disease will be useful.
What to look for
Using the patient’s pre-test
probability (based on clinical
presentation) and the likelihood
ratio (based on the study), one
can estimate the patient-specific
post-test probability.
 TOOLS FOR COMPUTATION AND INTERPRETATION

TABLE A.

Expressed as Definition Interpretation Dependence on

% disease
prevalence

Sensitivity Probability of a test result being Test B: 60%

positive given that the disease Test B is positive in 60% of patient WITH
really is there actual disease.
NO
Specificity Probability of a test result being Test B: 60%
negative given that the disease Test B is negative in 60% of patients
really is not there WITHOUT a disease.

PPV Probability of a patient actually Test B: 60%

having the disease given a A disease is actually present in 60% of YES
positive result patients WITH a positive test result.

NPV Probability of the patient not Test B: 60%

having that disease given that the A disease is actually absent in 60% of
test result was negative patients WITH a negative test result.

Table B.
Formula for likelihood ratios
Positive LR = ___Sensitivity__
100 - Specificity
Negative LR = (100 –Sensitivity)
Specificity

INTERPRETING LIKELIHOOD RATIOS

INTERPRETATION
0 = No change
LR more than >1
<3 = Weakly positive
3-10 = Moderately positive
>10 = Strongly positive

LR more than <1

>0.3 = Weakly negative
0.3 - 0.1 = Moderately negative
< 0.1= Strongly negative
BAYES NOMOGRAM