Public Health Sciences   PUBLIC HEALTH SCIENCES—Epidemiology and Biostatistics SECTION II 261

Quantifying risk (continued)

TERM DEFINITION EXAMPLE FORMULA
Mortality Number of deaths (in general or If 80 people in a town of 10,000 die over Deaths/1000 people per
rate due to specific cause) within a 2 years, mortality rate is 4 per 1000 per year.
population over a defined period. year.
Attack rate Proportion of exposed people who If 80 people in a town are exposed and People who become ill
become ill. 60 people become ill, attack rate is 75%. Total people exposed

Demographic As a country proceeds to higher levels of development, birth and mortality rates decline to varying
transition degrees, changing the age composition of the population.
Population pyramid
Age

Age

Age

Male Female
Male Female Female % Population % Population %
Male Population

Birth rate   

Mortality rate   
Life expectancy Short Long Long

Population Growing Stable Declining

Likelihood ratio probability of positive result in patient with disorder sensitivity TP rate
LR+ = = =
probability of positive result in patient without disorder 1 – specificity FP rate

probability of negative result in patient with disorder 1 – sensitivity FN rate

LR– = = =
probability of negative result in patient without disorder specificity TN rate

LR+ > 10 indicates a highly specific test, while LR– < 0.1 indicates a highly sensitive test.
Pretest probability × LR = posttest odds. Posttest probability = posttest odds / (posttest odds + 1).

Kaplan-Meier curve Graphic representation of event probability

1.0
(y-axis) vs length of time (x-axis). Useful for 0.9 Drug
Survival probability

displaying “time-to-event” data. Outcomes 0.8

examined may include any event, but 0.7
frequently include mortality. 0.6
Control
0.5
Survival probability = 1 – (event probability).
0.4
0.3
0.2

X Y Z
Time

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 262 SECTION II Public Health Sciences   PUBLIC HEALTH SCIENCES—Epidemiology and Biostatistics

Evaluation of Sensitivity and specificity are fixed properties Disease

–
diagnostic tests of a test. PPV and NPV vary depending on
disease prevalence in population being tested. PPV
TP FP = TP/(TP + FP)

Test
NPV
– FN TN = TN/(TN + FN)

Sensitivity Specificity Prevalence

TP + FN
= TP/(TP + FN) = TN/(TN + FP) (TP + FN + FP + TN)

Sensitivity (true- Proportion of all people with disease who test = TP / (TP + FN)
positive rate) positive, or the ability of a test to correctly = 1 – FN rate
identify those with the disease. SN-N-OUT = highly SeNsitive test, when
Value approaching 100% is desirable for ruling Negative, rules OUT disease
out disease and indicates a low false-negative High sensitivity test used for screening
rate.
Specificity (true- Proportion of all people without disease who = TN / (TN + FP)
negative rate) test negative, or the ability of a test to correctly = 1 – FP rate
identify those without the disease. SP-P-IN = highly SPecific test, when Positive,
Value approaching 100% is desirable for ruling rules IN disease
in disease and indicates a low false-positive High specificity test used for confirmation after a
rate. positive screening test
Positive predictive Probability that a person who has a positive test PPV = TP / (TP + FP)
value result actually has the disease. PPV varies directly with pretest probability
(baseline risk, such as prevalence of disease):
high pretest probability Ž high PPV
Negative predictive Probability that a person with a negative test NPV = TN / (TN + FN)
value result actually does not have the disease. NPV varies inversely with prevalence or pretest
probability
Possible cutoff values for vs – test result
Disease Disease A = 100% sensitivity cutoff value
Number of people

absent present B = practical compromise between specificity and sensitivity

C = 100% specificity cutoff value

TN TP Lowering the cutoff value: ↑ Sensitivity ↑ NPV

↑ ↑ ↑
B A (↑ FP FN) Specificity PPV
↑

FN FP
Raising the cutoff value: ↑ Specificity ↑ PPV
A B C B C ( ↑ FN FP)
↑ ↑
Sensitivity NPV
↑
↑

Test results

Receiver operating ROC curve demonstrates how well a diagnostic Ideal test (AUC = 1)
1
characteristic curve test can distinguish between 2 groups (eg, 1)
<
disease vs healthy). Plots the true-positive rate UC
<A
(sensitivity) against the false-positive rate .5
t (0
TP rate (sensitivity)

0.5)
(1 – specificity).
s
l te

C=
ua

The better performing test will have a higher AU

e(
Act

lu
area under the curve (AUC), with the curve va
it ve
ic
closer to the upper left corner. pr
ed
o
In diseases diagnosed based on low lab values N
(eg, anemia), the curve is flipped: lowering the
cutoff further Ž  FP,  FN; raising the cutoff
FP rate (1 – specificity) 1
Ž  FN,  FP.

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