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Comparative Test Evaluation: Methods and Challenges

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Abstract

The present paper has three objectives. First, methods for comparing alternative tests for the purpose of replacement of one test with a second presumably superior test are described. Second, problems in the interpretation of the relevance of different diagnostic thresholds (thresholds of positivity) that define who is and who is not a disordered gambler are examined and a potential solution offered in the form of a common quantitative measure of the risk of being a disordered gambler. Third, alternative methodologies are described as potential solutions to the lack of a gold or reference standard in the evaluation of new tests.

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Fig. 1

Adapted from Lord et al. (2011)

Fig. 2

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Notes

  1. In this notational scheme * = multiplication and / = division. Sometimes / is used as synonym for per.

  2. It may be argued that wanted help is not a true reference standard. Such arguments are subjective, however, and reference standards by definition involve a degree of subjectivity and some degree of disagreement is expected. Wanted help appears to be a plausible and credible definition for purposes of large epidemiologic surveys and in theory the question can be resolved through empirical analysis relative to other proposed reference standards to determine which reference standard is “best”. Moreover, if the same reference standard is applied then differences in accuracy are empirical and observable.

  3. A test with high sensitivity (specificity) but poor specificity (sensitivity) may be supplemented by applying a second test with high specificity (sensitivity) to all positive (negative) outcomes on the first test thus eliminating false positives (negatives) and increasing the overall specificity (sensitivity) of the testing process.

  4. Most presentations focus on the overlap in CI, however, the simpler ‘contained in’ language presented here is not uncommon and easy to understand. Many readers may be unfamiliar with the expansive and sometimes complex discussions in the statistical literature on CI.

  5. The results presented here will differ with those of Williams and Volberg since the reconstruction was based on original thresholds for CPGI (≥ 8), NODS (≥ 5) and SOGS (≥ 5) whereas the authors employed a threshold ≥ 3 for all tests.

  6. The authors note the procedure likely attracted greater numbers of [disordered] gamblers and heavier gamblers to participate, hence an increase in average levels of severity among gamblers in the survey. Since heavier gamblers more closely resemble disordered gamblers fpr will increase with severity.

  7. Most test evaluation studies treat false negatives and false positives as equally important; although statistically convenient for purposes of evaluation, in most situations and settings one or the other error will be of greater importance; hence initial thresholds reported in evaluation studies are unlikely to be applicable to other settings and populations and the need for replication is again emphasized.

  8. The expected decrease in LR+ reflects the greater number of true and false positive results that corresponds to an increase in P. The LR has been defined as the weight of the test evidence. The expected higher number of positive tests therefore carry less diagnostic information or weight hence a decrease in LR+. Similar logic applies to LR− and negative test results.

  9. In the practice setting the clinician acquires diagnostic information from a number of sources prior to applying a test for disordered gambling. Sources might include information from taking a clinical history, e.g., weekly gambling, information from a significant other, applying one or more supplemental tests, e.g., CAGE alcohol screen, and so on. Each piece of information raises or lowers the initial pre-test probability leading to some estimate including the diagnostic test resulting in different prior probabilities, e.g., 30%, for identifiable classes of gamblers.

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    Blase Gambino

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Gambino, B. Comparative Test Evaluation: Methods and Challenges. J Gambl Stud 34, 1109–1138 (2018). https://doi.org/10.1007/s10899-018-9745-3

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