Understanding the direction of bias in studies of diagnostic test accuracy.

Michael A. Kohn, Christopher R. Carpenter, Thomas B. Newman

Research output: Contribution to journalArticlepeer-review

155 Scopus citations


Ordering and interpreting diagnostic tests is a critical part of emergency medicine (EM). In evaluating a study of diagnostic test accuracy, emergency physicians (EPs) need to recognize whether the study uses case-control or cross-sectional sampling and account for common biases. The authors group biases in studies of test accuracy into five categories: incorporation bias, partial verification bias, differential verification bias, imperfect gold standard bias, and spectrum bias. Other named biases are either equivalent to these biases or subtypes within these broader categories. The authors go beyond identifying a bias and predict the direction of its effect on sensitivity and specificity, providing numerical examples from published test accuracy studies. Understanding the direction of a bias may permit useful inferences from even a flawed study of test accuracy.

Original languageEnglish
Pages (from-to)1194-1206
Number of pages13
JournalAcademic emergency medicine : official journal of the Society for Academic Emergency Medicine
Issue number11
StatePublished - Nov 2013


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