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a a+b
+ b
Screening
test result
_ c d c+d
True positives = a
Total with disease a+c
Specificity
True negatives d
=
Total without disease b+d
Positive Predictive Value
True positives a
=
Total screen positives a+b
Predictive value
• Positive predictive value = proportion of
positive screening tests that actually have
the disease
• “Consumer’s” value: A patient gets
screened for a disease. If the test result is
positive, what does it mean? Does he/she
have the disease?
Predictive value of a screening
test
• In general, positive predictive value (PPV) is
influenced by how common or rare the disease is,
in the population being screened.
• If screening test has < 100% specificity, PPV will
vary directly with prevalence: higher PPV when
test is applied to higher prevalence populations;
lower PPV when test is applied to lower
prevalence populations
Effect of prevalence on PPV
• Testing for antibodies to Herpes simplex
virus type 2 (HSV-2)
27,004 b
+
Screening
test result
_ c d
28,100 100,000
30 y/o female FP clinic patient, Seattle
(cont.)
• 100,000 – 28,100 = 71,900 women will be
uninfected.
• Specificity of the screening test = 97%, so
71,900 x 0.97 = 69,743 of the uninfected
women will be correctly identified by the
screening test as being screen -
2 X 2 contingency table
True disease present
Yes No
27,004 b
+
Screening
test result
_ c 69,743
27,004 2,157
+
Screening
test result
_ 1,096 69,743
True positives a
Total screen positives =a+b
27,004
29,161 = 92.6%
Example 2: 24 y/o female FP clinic patient
with 1-2 lifetime sexual partners, Seattle
• HSV-2 prevalence = 2.7%
• If 100,000 women in this population are
definitively tested for HSV-2:
• 2,700 will have true HSV-2 infection
• Sensitivity of screening test = 96.1%, so
2,700 x 0.961 = 2,595 of the infected
women will be correctly identified by the
screening test as being screen +
2 X 2 contingency table
True disease present
Yes No
2,595 b
+
Screening
test result
_ c d
2,700 100,000
24 y/o female FP clinic patient, Seattle
(cont.)
• 100,000 – 2,700 = 97,300 women will be
uninfected.
• Specificity of the screening test = 97%, so
97,300 x 0.97 = 94,381 of the uninfected
women will be correctly identified by the
screening test as being screen -
2 X 2 contingency table
True disease present
Yes No
2,595 b
+
Screening
test result
_ c 94,381
2,595 2,919
+
Screening
test result
_ 105 94,381
True positives a
Total screen positives =a+b
2,595
5,514 = 47.1%
Effect of prevalence on PPV
• In the higher prevalence (older, greater
number of sex partners) population, 92.6%
of those testing positive are truly HSV-2
infected
• In the lower prevalence (younger, lower
number of sex partners) population, less
than 50% of those testing positive are truly
HSV-2 infected
Final thoughts
May need to be “selective” in applying screening
tests.
Cannot correctly interpret a screening test result
without an understanding/appreciation of the
“predictive value” of the screening test.
Even tests with excellent sensitivity and specificity,
may have low positive predictive values when
applied to populations with low prevalence.