Diagnosis and Screening: Likelihood ratios; pre and post test probability
What is a likelihood ratio?
The likelihood ratio provides a direct estimate of how much a test result will change the odds of having a disease, and incorporates both the sensitivity and specificity of the test.
The likelihood ratio for a positive result (LR+) tells you how much the odds of the disease increase when a test is positive.
The likelihood ratio of a positive test result (LR+) is sensitivity divided by (1- specificity)
The likelihood ratio for a negative result (LR-) tells you how much the odds of the disease decrease when a test is negative.
*Note that the calculation of likelihood ratios is currently not tested as a skill in the UK MFPH Part A examination.
Interpretation of Likelihood Ratios
The further away a likelihood ratio (LR) is from 1, the stronger the evidence for the presence or absence of disease.
LR >1 indicates that the test result is associated with the presence of the disease.
LR <0.1 indicates that the test result is associated with the absence of disease.
Pre-test probability (~ prevalence)
This is the proportion of people in the population at risk who have the disease at a specific time or time interval, i.e. the point prevalence or the period prevalence of the disease. In other words, it is the probability −before the diagnostic test is performed − that a patient has the disease. Pre-test probabilities may be estimated from routine data, practice data or clinical judgement.
This is the proportion of patients testing positive who truly have the disease. It is similar to the positive predictive value but apart from the test performance also includes a patient based probability of having disease
Post-test probability =
(1 + Post-test odds)
Using Pre- and Post-test probability and LR
By comparing the pre- and post-test probabilities, it is possible to determine whether probability of diagnosis has risen (i.e. the post-test probability has increased) or fallen (i.e. post-test probability has decreased). In this way, it is possible to provide comprehensive information about a screening test in order to enable informed choice. In practice assessing post-test probability is commonly done by using a Likelihood Ratio Nomogram (below)
Summary of calculations of key features of screening tests
© Dr Murad Ruf and Dr Oliver Morgan 2008