Comparing accuracy in an unpaired post-market device study with incomplete disease assessment

The sensitivity and specificity of a new medical device are often compared relative to that of an existing device by calculating ratios of sensitivities and specificities. Although it would be ideal for all study subjects to receive the gold standard so true disease status was known for all subjects, it is often not feasible or ethical to obtain disease status for everyone. This paper proposes two unpaired designs where each subject is only administered one of the devices and device results dictate which subjects are to receive disease verification. Estimators of the ratio of accuracy and corresponding confidence intervals are proposed for these designs as well as sample size formulae. Simulation studies are performed to investigate the small sample bias of the estimators and the performance of the variance estimators and sample size formulae. The sample size formulae are applied to the design of a cervical cancer study to compare the accuracy of a new device with the conventional Pap smear.