ROC curve estimation when covariates affect the verification process

A receiver operating characteristic (ROC) curve is commonly used to measure the accuracy of a medical test. It is a plot of the true positive fraction (sensitivity) against the false positive fraction (1-specificity) for increasingly stringent positivity criterion. Bias can occur in estimation of an ROC curve if only some of the tested patients are selected for disease verification and if analysis is restricted only to the verified cases. This bias is known as verification bias. In this paper, we address the problem of correcting for verification bias in estimation of an ROC curve when the verification process and efficacy of the diagnostic test depend on covariates. Our method applies the EM algorithm to ordinal regression models to derive ML estimates for ROC curves as a function of covariates, adjusted for covariates affecting the likelihood of being verified. Asymptotic variance estimates are obtained using the observed information matrix of the observed data. These estimates are derived under the missing-at-random assumption, which means that selection for disease verification depends only on the observed data, i.e., the test result and the observed covariates. We also address the issues of model selection and model checking. Finally, we illustrate the proposed method on data from a two-phase study of dementia disorders, where selection for verification depends on the screening test result and age.