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Spectrum bias: why generalists and specialists do not connect
St Vincent’s Hospital; Melbourne, Victoria, Australia
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Coronary artery disease (CAD) exists in a spectrum: it ranges from the early lesions seen in young victims of trauma1 through to sudden cardiac death or myocardial infarction with cardiogenic shock. Yet diagnostic studies that compare the clinical features and diagnostic tests with a reference standard usually act as if the disease was a homogeneous entity. This dichotomous approach to diagnostic accuracy is measured as sensitivity and specificity, likelihood ratios, diagnostic odds ratios, and the area under the receiver-operator characteristic curve.2 Ransahoff and Feinstein recognised that "unless an appropriately broad spectrum is chosen for the diseased and non-diseased patients who comprise the study population," the diagnostic test may result in spurious estimates of diagnostic performance.3 However, this article argues that it is not possible to have a sufficiently broad spectrum of patients to be of value in a single description of diagnosis, prognosis, and therapy of any common condition such
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