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or clinicians to use a diagnostic test in clinical prac- tice, they need to know how well the test distin- guishes between those who have the suspected dis- ease or condition and those who do not. If investigators choose clinically inappropriate populations for their study of a diagnostic test and thereby introduce what is some- times called spectrum bias, the results may seriously mis- lead clinicians. In this article we present a series of examples that illus- trate why clinicians need to pay close attention to the pop- ulations enrolled in studies of diagnostic test performance before they apply the results of those studies to their own patients. After working through these examples, you should understand which characteristics of a study population are likely to result in misleading interpretations of test results and which are not. The tips in this article are adapted from approaches de- veloped by educators with experience in teaching evidence- based medicine principles to clinicians. 1,2

Tips for learners of evidence-based medicine: 5. The effect of spectrum of disease on the performance of diagnostic tests