Normal Distribution
nothing is called 95% until it has been counted
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 6 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 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.

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 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

Named alongside it

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

Base ratePredictive valueSensitivity and specificityOdds formPosteriorPriorSequential testingThresholdBase rate fallacyThe Bayes factorClosed formConditional independence

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