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November 2022 The Covariate-Adjusted ROC Curve: The Concept and Its Importance, Review of Inferential Methods, and a New Bayesian Estimator
Vanda Inácio, María Xosé Rodríguez-Álvarez
Author Affiliations +
Statist. Sci. 37(4): 541-561 (November 2022). DOI: 10.1214/21-STS839


Accurate diagnosis of disease is of fundamental importance in clinical practice and medical research. Before a medical diagnostic test is routinely used in practice, its ability to distinguish between diseased and nondiseased states must be rigorously assessed. The receiver operating characteristic (ROC) curve is the most popular used tool for evaluating the diagnostic accuracy of continuous-outcome tests. It has been acknowledged that several factors (e.g., subject-specific characteristics such as age and/or gender) can affect the test outcomes and accuracy beyond disease status. Recently, the covariate-adjusted ROC curve has been proposed and successfully applied as a global summary measure of diagnostic accuracy that takes covariate information into account. The aim of this paper is three-fold. First, we motivate the importance of including covariate-information, whenever available, in ROC analysis and, in particular, how the covariate-adjusted ROC curve is an important tool in this context. Second, we review and provide insight on the existing approaches for estimating the covariate-adjusted ROC curve. Third, we develop a highly flexible Bayesian method, based on the combination of a Dirichlet process mixture of additive normal models and the Bayesian bootstrap, for conducting inference about the covariate-adjusted ROC curve. A simulation study is conducted to assess the performance of the different methods and it also demonstrates the ability of our proposed Bayesian model to successfully recover the true covariate-adjusted ROC curve and to produce valid inferences in a variety of complex scenarios. The methods are applied to an endocrine study where the goal is to assess the accuracy of the body mass index, adjusted for age and gender, for detecting clusters of cardiovascular disease risk factors.

Funding Statement

The first author expresses her gratitude for the support received by FCT (Fundação para a Ciência e a Tecnologia, Portugal) through the projects PTDC/MAT-STA/28649/2017 and UID/MAT/00006/2019.
The second author expresses her gratitude for the support received by the Basque Government (BERC 2018-2021 program), by the Spanish Ministry of Science, Innovation, and Universities (BCAM Severo Ochoa accreditation SEV-2017-0718), and through project MTM2017-82379-R funded by AEI/FEDER, UE.


We thank the Editors and reviewers whose constructive comments led to a much improved version of the article. We would like to acknowledge the Galician Endocrinology and Nutrition Foundation (Fundación de Endocrinoloxía e Nutrición Galega—FENGA) and Carmen Cadarso-Suárez for having supplied the database used in this study.


Download Citation

Vanda Inácio. María Xosé Rodríguez-Álvarez. "The Covariate-Adjusted ROC Curve: The Concept and Its Importance, Review of Inferential Methods, and a New Bayesian Estimator." Statist. Sci. 37 (4) 541 - 561, November 2022.


Published: November 2022
First available in Project Euclid: 13 October 2022

Digital Object Identifier: 10.1214/21-STS839

Keywords: Classification accuracy , covariate-adjustment , decision threshold , diagnostic test , Dirichlet process (mixture) model , receiver operating characteristic curve

Rights: Copyright © 2022 Institute of Mathematical Statistics


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Vol.37 • No. 4 • November 2022
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