Using a combination of reference tests to assess the accuracy of a new diagnostic test

Stat Med. 1999 Nov 30;18(22):2987-3003. doi: 10.1002/(sici)1097-0258(19991130)18:22<2987::aid-sim205>;2-b.


Often the accuracy of a new diagnostic test must be assessed when a perfect gold standard does not exist. Use of an imperfect reference test biases accuracy estimates of the new test. This paper reviews existing approaches to this problem including discrepant resolution and latent class analysis. Deficiencies with these approaches are identified. A new approach is proposed that combines the results of several imperfect reference tests to define a better reference standard. We call this the composite reference standard (CRS). Using the CRS, accuracy can be assessed using multi-stage sampling designs. Maximum likelihood estimates of accuracy and expressions for the variance of sensitivity and specificity are provided. Data from clinical literature on the detection of Chlamydia trachomatis are used to illustrate and compare the different approaches. Advantages of the CRS relative to other approaches include that the CRS is explicitly defined, does not depend on the results of the new test under investigation, and is easy to interpret.

Publication types

  • Comparative Study
  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • Cell Culture Techniques
  • Chlamydia Infections / diagnosis
  • Chlamydia Infections / epidemiology
  • Chlamydia trachomatis / isolation & purification
  • Diagnostic Techniques and Procedures / standards*
  • Diagnostic Techniques and Procedures / statistics & numerical data
  • Female
  • Humans
  • Immunoenzyme Techniques
  • Male
  • Polymerase Chain Reaction
  • Predictive Value of Tests*
  • Prevalence
  • Reproducibility of Results*
  • Sensitivity and Specificity