Research lecture 4

Dr. Sorin Ioacara

The precision and accuracy of a medical test are two different things. Based on their combinations
medical tests can have:

a. low precision and low accuracy

b. low precision and high accuracy
c. high precision and low accuracy
d. high precision and high accuracy

The precision of a test refers to its ability of having a low dispersion of the results when repeating it
from the same sample (figure 1). A high precision means a low random error. However, precision
doesn’t give any information about whether the measurement is correct. High precision means that
repeating the test will give us roughly the same result (low standard deviation), which can be correct
or (very) incorrect.

The accuracy of a test refers to its ability of being very close to the correct (reference) result (figure
1). A high accuracy means a low systematic error. However, accuracy doesn’t give any information
about the dispersion of repeat measurements. High accuracy means that repeating the test will give
us values that are very close to the perfect (reference) result (mean value very close to reference),
which can be either above or below the reference by a small or high amount.

Figure 1. Accuracy and precision

1
Example: a new faster and cheaper medical test is verified against the current very expensive, but
very good test (used here as reference). Repeating the new test for 100 times gives values that can
be described by mean and standard deviation. The test is said to have a low precision and low
accuracy if the results differ very much one from another and their mean value also differs
significantly from the reference. The test is said to have a low precision and high accuracy if the
results differ very much one from another, but their mean value is very close to the reference. The
test is said to have a high precision and low accuracy if the results don’t differ very much one from
another, but their mean value differs significantly from the reference. The test is said to have a high
precision and high accuracy if the results don’t differ very much one from another and their mean
value also is very close to the reference.

Confounding variable is a variable that corelates with both the risk factor and the outcome, and
therefore may explain some of the correlation found between the risk factor and the outcome.
Failure to adjust for the confounding variables can lead to false conclusions. Example: a study found
that there is a strong correlation between birth order and risk of being born with Down syndrome,
and concluded that birth order is a risk factor for Down syndrome. However, another variable
(confounding) called maternal age strongly correlates both with birth order and risk of Down
syndrome. Adjusting for the confounding variable called maternal age eliminates any correlation
between birth order and Down syndrome. Therefore, the new conclusion would be that maternal
age and not birth order is a strong risk factor for the Down syndrome.

Positive predictive value of a medical diagnostic test is the probability that subjects with a positive
test truly have the disease. A high positive predictive value means that most of the subjects with a
positive test will be later confirmed as being part of the group that have the disease.

Positive predictive value (PPV) formula:

Example: following a thyroid ultrasound examination the patient is informed that he has a nodule
that has all the ultrasound criteria for thyroid cancer. The patient is asking the doctor how certain he
is that the nodule is cancer, i.e. what is the PPV of the ultrasound examination in identifying thyroid
cancer. For a PPV of 0.7, the answer would be that given the ultrasound result positive for thyroid
cancer suspicion, in 70% of cases similar with this one the thyroid cancer was confirmed using
anatomopathological examination (reference test) of the nodule (following thyroidectomy).

2
Negative predictive value of a medical diagnostic test is the probability that subjects with a negative
test truly don’t have the disease. A high negative predictive value means that most of the subjects
with a negative test will be later confirmed as being part of the group that don’t have the disease.

Negative predictive value (NPV) formula:

Example: following a thyroid ultrasound examination the patient is informed that he has a nodule
that has all the ultrasound criteria for a benign nodule. The patient is asking the doctor how certain
he is that the nodule is not cancer, i.e. what is the NPV of the ultrasound examination for thyroid
cancer evaluation. For a NPV of 0.9, the answer would be that given the ultrasound result negative
for thyroid cancer suspicion, in 90% of cases similar with this one the thyroid cancer wasn’t found
using anatomopathological examination (reference test) of the nodule (following thyroidectomy).

Reverse causality is a situation in which the alleged outcome determines the appearance of the
presumed risk factor, and therefore the initially established risk factor and outcome are switching
roles. Example: in an observational study of type 2 diabetes patients treated with oral medication for
10 years it was found that insulin treatment initiation due to high blood glucose value during the last
2 months was associated with a significant increase in cancer incidence for the next 30 days. The
initial conclusion was that insulin initiation is a risk factor for short term cancer incidence. Reverse
causality refers to the possibility that a yet undiagnosed cancer was responsible for the high blood
glucose values that determined insulin initiation. In this case, the cancer is the risk factor for insulin
initiation (the outcome).