Intended for healthcare professionals

Education And Debate

When can a risk factor be used as a worthwhile screening test?

BMJ 1999; 319 doi: (Published 11 December 1999) Cite this as: BMJ 1999;319:1562
  1. N J Wald, professor (,
  2. A K Hackshaw, lecturera,
  3. C D Frost, senior lecturerb
  1. a Department of Environmental and Preventive Medicine, Wolfson Institute of Preventive Medicine, St Bartholomew's Hospital, London EC1M 6BQ
  2. b Medical Statistics Unit, London School of Hygiene and Tropical Medicine, London WC1E 7HT
  1. Correspondence to: N J Wald
  • Accepted 19 July 1999

One of the most important areas of medical inquiry is the identification of risk factors for specific disorders. Such research is usually aimed at discovering new causes of a disease, but risk factors can also be used as screening tests. The fact that a risk factor must be very strongly associated with a disorder if it is to be a worthwhile screening test is not widely recognised. If this were better understood, fewer risk factors would be proposed unnecessarily as screening tests. Serum cholesterol measurement, for example, would probably never have been considered seriously as a screening test for ischaemic heart disease. Although a high cholesterol concentration is a strong risk factor for ischaemic heart disease in aetiological terms, the association is not sufficiently strong for it to be used as a screening test—in practice, its screening performance is poor.1

In this article we specify the quantitative relation between risk factors and screening tests and show how strongly a risk factor needs to be associated with a disease before it is likely to be a useful screening test. For simplicity, we consider only risk factors with a Gaussian distribution, though the general principles we present can be applied to all frequency distributions.

Summary points

To be a worthwhile screening test, a risk factor must be strongly associated with a disorder

The strength of association between a risk factor and a disorder can be quantified by the relative risk or relative odds (odds ratio)

A risk factor can also be considered as a screening test, and its association with the disorder can be quantified as the detection rate for a specified false positive rate

There is a direct numerical equivalence between the relative odds and the detection rate for specified false positive rate that does not depend on the incidence or prevalence …

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