Evaluation of diagnostic tests when there is no gold standard. A review of methods
Open accessAbstract
OBJECTIVE: To generate a classification of methods to evaluate medical tests when there is no gold standard. METHODS: Multiple search strategies were employed to obtain an overview of the different methods described in the literature, including searches of electronic databases, contacting experts for papers in personal archives, exploring databases from previous methodological projects and cross-checking of reference lists of useful papers already identified. RESULTS: All methods available were classified into four main groups. The first method group, impute or adjust for missing data on reference standard, needs careful attention to the pattern and fraction of missing values. The second group, correct imperfect reference standard, can be useful if there is reliable information about the degree of imperfection of the reference standard and about the correlation of the errors between the index test and the reference standard. The third group of methods, construct reference standard, have in common that they combine multiple test results to construct a reference standard outcome including deterministic predefined rules, consensus procedures and statistical modelling (latent class analysis). In the final group, validate index test results, the diagnostic test accuracy paradigm is abandoned and research examines, using a number of different methods, whether the results of an index test are meaningful in practice, for example by relating index test results to relevant other clinical characteristics and future clinical events. CONCLUSIONS: The majority of methods try to impute, adjust or construct a reference standard in an effort to obtain the familiar diagnostic accuracy statistics, such as sensitivity and specificity. In situations that deviate only marginally from the classical diagnostic accuracy paradigm, these are valuable methods. However, in situations where an acceptable reference standard does not exist, applying the concept of clinical test validation can provide a significant methodological advance. All methods summarised in this report need further development. Some methods, such as the construction of a reference standard using panel consensus methods and validation of tests outwith the accuracy paradigm, are particularly promising but are lacking in methodological research. These methods deserve particular attention in future research.
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The literature search was based on the principle of theoretical saturation.
“We based our literature search on the principle of theoretical saturation [17, 18], with the aim of identifying all relevant recommendations, rather than all relevant articles.”
From Methods to systematically review and meta-analyse observational studies: a systematic scoping review of recommendations (2018) · cites this paper as [18]
Locating methodological papers in electronic databases was challenging because relevant articles may be indexed differently and there is no key word to search for this type of article.
“Locating methodological papers in electronic databases was challenging: relevant articles may be indexed differently and there is no key word to search for this type of article [18].”
From Methods to systematically review and meta-analyse observational studies: a systematic scoping review of recommendations (2018) · cites this paper as [18]
The search was guided by the methodological principle of theoretical saturation.
“However, our search was guided by the methodological principle of theoretical saturation [17, 18].”
From Methods to systematically review and meta-analyse observational studies: a systematic scoping review of recommendations (2018) · cites this paper as [18]
Once a set of methodological articles covering all relevant methodological aspects is identified, additional searches add little to the ideas already present in the initial set of articles.
“Once a set of methodological articles covering all relevant methodological aspects is identified, additional searches add little to the ideas already present in the initial set of articles.”
From Methods to systematically review and meta-analyse observational studies: a systematic scoping review of recommendations (2018) · cites this paper as [18]
Theoretical saturation suggests that identifying every article is not required in methodological research.
“Theoretical saturation suggests that identifying every article is not required in methodological research.”
From Methods to systematically review and meta-analyse observational studies: a systematic scoping review of recommendations (2018) · cites this paper as [18]
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Self-citation
- Authors
- Rutjes, A., Reitsma, J., Coomarasamy, A., Khan, K., & Bossuyt, P.
- Affiliations
- Amsterdam UMC Location University of Amsterdam (NL)
- University of Birmingham (GB)
- Venue
- Health Technology Assessment
- Published
- 2007-12
- Volume
- 11
- Issue
- 50
- Pages
- iii, ix-51
- ISSN
- 1366-5278 (ISSN-L)
- 2046-4924
- OpenAlex
- W2143712591
- Cited by
- 524
- References
- 175
- Citations by year
- 2026: 21 · 2025: 21 · 2024: 20 · 2023: 23 · 2022: 36 · 2021: 34 · 2020: 39 · 2019: 38 · 2018: 57 · 2017: 31 · 2016: 33 · 2015: 27 · 2014: 29 · 2013: 27 · 2012: 30
- FWCI
- 2.43
- Type
- journal article
- Language
- en
- Open access
- diamond
- doi.org
- Locations
- Health Technology Assessment (publishedVersion, cc-by)
- PubMed (publishedVersion)
- Pure Amsterdam UMC (publishedVersion)
- IRIS UNIMORE (University of Modena and Reggio Emilia) (submittedVersion, cc-by)
- Data Archiving and Networked Services (DANS) (submittedVersion)
- DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion)
- IRIS UNIMORE (University of Modena and Reggio Emilia) (submittedVersion)
- University of Birmingham Research Portal (University of Birmingham) (submittedVersion)
- Funders
- Health Technology Assessment programme (06/90/23)
- Topics
- Social Sciences › Decision Sciences › Statistics, Probability and Uncertainty › Meta-analysis and systematic reviews
- Physical Sciences › Mathematics › Statistics and Probability › Statistical Methods in Epidemiology
- Social Sciences › Decision Sciences › Statistics, Probability and Uncertainty › Reliability and Agreement in Measurement
- Keywords
- diagnostic accuracy, absence of gold standard, reference materials, imperfect reference standard, latent class analysis, sensitivity and specificity, methodological review
- MeSH terms
- Humans, Reference Standards, Sensitivity and Specificity, Process Assessment, Health Care, Diagnostic Techniques and Procedures
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
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