Concept

Screening — where it appears

Testing a population for a condition most of them do not have, where the arithmetic of predictive value rather than of accuracy decides what a positive is worth. At low prevalence most positives are false however good the test is, and the repair is a second test rather than a better first one.

Named by 8 essays across 3 fields — each of them below, with the objects they name alongside it.

What a second positive is worth, prevalence 0.10%. A 90% sensitive, 95% specific test. One positive gives 1.77%. Two independent positives give 24.49%, which is what multiplying the likelihood ratios says. At a correlation of 0.1 between the tests' errors it is 10.16%, and at 0.5 it is 3.16%.

The second test that is not a second opinion

Two positives from a 90/95 test on a one-in-a-thousand condition give a 24.49% chance of disease if the tests are independent. At a correlation of 0.1 between their errors it is 10.16%, and at 0.5 it is 3.16% — barely more than the 1.77% one positive was worth.

screening · Baserate

What a positive test means, sensitivity 90%, specificity 95%. At a prevalence of one in a thousand, 98 of every hundred positives are false. At one in 10, 33 are. The test has not changed.

What a positive test is worth

A test that is 90% sensitive and 95% specific sounds accurate. For a condition affecting one person in a thousand, 98% of its positive results are wrong, and a worse test on a commoner condition beats a better test on a rare one.

paradox · Baserate

The operating characteristic, and the point that minimises harm at 0.10% prevalence. The published pair — 90% sensitive, 95% specific — is the open mark. With a miss costing 100 times a false alarm and a prevalence of 0.10%, the threshold that minimises expected cost sits at 74.7% sensitivity and 98.81% specificity, with a predictive value of 5.9%.

The test is a point somebody chose

A test reported as 90% sensitive and 95% specific is not two properties of a test. It is one property read at a threshold, and the threshold that minimises harm runs from 3.05 standard deviations of the score at a prevalence of one in ten thousand to −0.12 at one in two — 45% of cases detected at one end and 99.9% at the other.

screening · Baserate

Estimating a prevalence of 0.10% from 1,000 tests. The positive rate reads 5.09%, which is 50.9 times the truth. The Rogan-Gladen correction averages 0.100% — unbiased — with a standard deviation of 0.820 points against the positive rate's 0.695, and it comes out negative on 48.6% of samples.

The prevalence the test has to estimate

Every predictive value takes a prevalence as given, and the prevalence is usually estimated from the same test's positive rate. At a true prevalence of one in a thousand that rate reads 5.09% — fifty times the truth — and the correction that inverts it is unbiased, 18% more variable, and negative on 48.6% of samples of a thousand.

screening · Baserate

The base rate was always Bayes

The screening arithmetic everybody finds counter-intuitive is a posterior update with a prior of one in a thousand. Naming it that way turns a famous puzzle into an instance of a rule, and makes the sequential version obvious.

bayes · Baserate

Thirty surveys of a thousand people, true prevalence 0.1%, test 90% sensitive and 95% specific. Each row is one survey. The thin bar is the corrected estimate ± 1.96 standard errors; the heavy bar is the exact interval for the positive rate carried through the correction; the tick is the one-sided 95% upper limit. 30 of the thirty printed intervals reach below zero and 0 lie entirely below it.

An upper limit is the finding

A survey of a thousand people with a 90%-sensitive, 95%-specific test, estimating a prevalence of one in a thousand, prints a corrected 95% interval that covers the truth 95.17% of the time — and reaches below zero in 97.95% of surveys and lies entirely below zero in 3.35%. Coverage is not the problem. The problem is what the interval can say, and the honest summary of a typical survey is one number: the prevalence is below 1.64%. Bringing that limit down to twice the truth takes 184,521 people at this specificity and 5,083 with a test that never gives a false positive.

screening · Baserate

A cohort screened once, the top tenth enrolled, and followed up with nothing given — correlation 0.6. 2000 people read once at screening and once at follow-up, with a test–retest correlation of 0.6 and no treatment. The 215 above a cut at the top ten per cent of one reading (1.282 standard deviations) are enrolled. Their mean screening reading is 1.744 and their mean follow-up reading 0.982, a fall of 0.762 ± 0.055 with nothing done to anyone. The closed form for the fall is (1 − ρ) times the truncated-normal mean, (1 − 0.6) × 1.755 = 0.702.

The measurement that got them enrolled

Enrol the top tenth of one screening reading and give them nothing, and they fall by 0.702 standard deviations at follow-up. Measured from a fresh reading taken after enrolment they fall by nothing. Averaging ten screening readings still leaves 0.101, and it takes twenty-one to get under 0.05.

paradox · Rtm

A threshold that jumps

When a test's scores are equally spread in the healthy and the diseased, the harm-minimising threshold slides smoothly as the prevalence changes. Make the diseased scores twice as spread — the ordinary shape of a group that mixes mild and severe cases — and keep the published 90/95 pair, and the best threshold flags 81.1% of healthy people at a prevalence just under 25.7% and every healthy person just above it. At three times the spread it jumps from 45.7% to everyone at 13.0%. A threshold that jumps cannot be given as a formula; it has to be given with the second-best point beside it.

screening · Baserate

Named alongside it

The objects these essays reach for when they reach for this one.

Base rate Sensitivity and specificity Predictive value Prevalence Decision threshold Expected loss Likelihood ratio Misclassification Odds form Posterior Prior ROC curve

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