The validation of screening tests: meet the new screen same as the old screen?

The focus of this report is to examine the process of validation of new screening tests designed to detect the problem gambler in research and practice settings. A hierarchical or phases of evaluation model is presented as a conceptual framework to describe the basic features of the validation process and its implications for application and interpretation of test results. The report describes a number of threats to validity in the form of sources of unintended bias that when unrecognized may lead to incorrect interpretations of study results and the drawing of incorrect conclusions about the usefulness of the new screening tests. Examples drawn from the gambling literature on problem gambling are used to illustrate some of the more important concepts including spectrum bias and clinical variation in test accuracy. The concept of zones of severity and the bias inherent in selecting criterion thresholds are reviewed. A definition of reference or study gold standard is provided. The use of 2-stage designs to establish validity by efficiently using reference standards to determine indices of accuracy and prevalence is recommended.