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MEDICINE

REVIEW ARTICLE

Part 12 of a Series on Evaluation of Scientific Publications

SUMMARY

Background: The interpretation of scientific articles often

M pirical studies and the results of these are

usually presented and analyzed with statistical

requires an understanding of the methods of inferential methods. It is therefore an advantage for any physician

statistics. This article informs the reader about frequently

if he/she is familiar with the frequently used statistical

used statistical tests and their correct application.

tests, as this is the only way he or she can evaluate the

Methods: The most commonly used statistical tests were statistical methods in scientific publications and thus

identified through a selective literature search on the correctly interpret their findings. The present article

methodology of medical research publications. These tests will therefore discuss frequently used statistical tests

are discussed in this article, along with a selection of for different scales of measurement and types of

other standard methods of inferential statistics. samples. Advice will be presented for selecting statisti-

Results and conclusions: Readers who are acquainted not cal tests—on the basis of very simple cases.

just with descriptive methods, but also with Pearson’s

chi-square test, Fisher’s exact test, and Student’s t test Statistical tests used frequently in medical

will be able to interpret a large proportion of medical studies

research articles. Criteria are presented for choosing the In order to assess which statistical tests are most often

proper statistical test to be used out of the most used in medical publications, 1828 publications were

frequently applied tests. An algorithm and a table are taken from six medical journals in general medicine,

provided to facilitate the selection of the appropriate test. obstetrics and gynecology, or emergency medicine. The

result showed that a reader who is familiar with de-

scriptive statistics, Pearson’s chi-square test, Fisher’s

exact test and the t-test, should be capable of correctly

interpreting the statistics in at least 70% of the articles

(1). This confirmed earlier studies on frequently used

statistical tests in medical scientific literature (2, 3).

There have however been changes over time in the

spectrum of the tests used. A survey of the analytical

statistical procedures used in publications of the journal

Pediatrics in the first six months of 2005 found that the

proportion of inferential methods had increased from

48 to 89% between 1982 and 2005 (4). There was also a

trend towards more complex test procedures. Never-

theless, here too, the most frequent tests were the t-test,

the chi-square test, and Fisher’s exact test. This article

will accordingly discuss these tests and their proper ap-

plication, together with other important statistical tests.

If the reader is familiar with this limited number of

tests, he/she will be capable of interpreting a large pro-

portion of medical publications. Information about the

Cite this as: Dtsch Arztebl Int 2010; 107(19): 343–8 rarer statistical tests can be found in the corresponding

DOI: 10.3238/arztebl.2010.0343 articles, in advanced literature (5–7), or by consulting

an experienced statistician.

What is the purpose of statistical tests?

Clinical studies [for example, [5, 8]) often compare the

Medizinischer Dienst der Krankenversicherung Rheinland-Pfalz (MDK), Referat

Rehabilitation/Biometrie: Dr. rer. nat. Röhrig efficacy of a new preparation in a study group with the

Institut für Medizinische Biometrie, Epidemiologie und Informatik (IMBEI) Uni- efficacy of an established preparation, or a placebo, in a

versitätsmedizin Mainz: Prof. Dr. rer. nat. Hommel, Prof. Dr. rer. nat. Blettner control group. Aside from a pure description (9), we

Deutsches Ärzteblatt International | Dtsch Arztebl Int 2010; 107(19): 343–8 343

MEDICINE

BOX unlikely that the null hypothesis is correct and the null

hypothesis is accordingly rejected. The result is then

“statistically significant at the level α”. The statistical

Steps in a statistical test test is thus a decision whether the observed value can

● Statement of the question to be answered by the study be explained by chance, or whether it is greater than

chance (statistically significant). The terms “level of

● Formulation of the null and alternative hypotheses significance” and the principle of the interpretation of

● Decision for a suitable statistical test p-values have already been discussed (10, 11). The

● Specification of the level of significance (for example, underlying steps in a statistical test are shown once

0.05) again in the Box.

● Performance of the statistical test analysis: calculation It is possible to be mistaken, either in the rejection or

of the p-value in the retention of the null hypothesis. The reason for

this is that the values exhibit scatter, as, for example,

● Statistical decision: for example not all patients react equally to a drug. An “error of the

– p<0.05 leads to rejection of the null hypothesis and first type” is the mistaken rejection of the null hypo-

acceptance of the alternative hypothesis thesis; the maximal probability of this error is the level

– p≥0.05 leads to retention of the null hypothesis of significance α. This is often chosen to be 5% (10,

● Interpretation of the test result 11). An “error of the second type” is the mistaken reten-

tion of the null hypothesis; the probability of this is ß,

which is the same as 1 minus the power of the study.

The power of the study is specified before the study

starts and depends on the sample size, as well as other

would like to know whether the observed differences factors. A power of 80% is often selected (10, 11).

between the treatment groups are just random or are

really present. This is because differences can be due to Important steps in the decision

chance variability (scatter) in a parameter, such as the for a statistical test

success of the treatment in the study group. The decision for a statistical test is based on the scien-

tific question to be answered, the data structure, and the

Definition study design. Before the data are recorded and the sta-

If a scientific question is to be examined by comparing tistical test is selected, the question to be answered and

two or more groups, one can perform a statistical test. the null hypothesis must be formulated. The test and the

This means that a null hypothesis must be formulated, level of significance must be specified in the study

which can in principle be rejected. Moreover, a suitable protocol before the study is performed. It must be

test parameter must be identified (10, 11). decided whether the test should be one-tailed or two-

For example, a clinical study might investigate tailed. If the test is two-tailed, this means that the direc-

whether an antihypertensive drug works better than tion of the expected difference is unclear. One does not

placebo. The test variable may then be the reduction in know whether there is a difference between the new

diastolic blood pressure, calculated from the mean dif- drug and placebo with respect to efficacy. It is unclear

ference in blood pressure between the active treatment in which direction the difference may be. (The new

and placebo groups. The null hypothesis is then: “There drug might even work less well than the placebo). A

is no difference between the active treatment and the one-tailed test should only be performed when there is

placebo with respect to antihypertensive activity” clear evidence that the intervention should only act in

(effect = 0). one direction.

A statistical test then calculates the probability of ob- The outcome variable (endpoint) is defined at the

taining the observed data (or even more extreme data), same time the question to be answered is formulated.

if the null hypothesis is correct. A small p-value means Two criteria are decisive for the selection of the statisti-

that this probability is slight. The null hypothesis is re- cal test:

jected if the p-value is less than a level of significance ● The scale of measurement of the test variable

which has been defined in advance. A test variable (test (continuous, binary, categorical)

statistic) is calculated from the observed data and this ● The type of study design (paired or unpaired).

forms the basis of the statistical test. In our case, this

might be the difference in mean blood pressure after six Scales of measurement: continuous, categorical, or binary

months. If specific assumptions are made about the dis- The different scales of measurement have already been

tribution of the data (for example, normal distribution), discussed in the articles on study design and descriptive

the theoretical (expected) distribution of the test statistics, under the selection of suitable measures and

variable can be calculated. methods of illustration (9, 12).

The value of the test variable calculated from the For example, in the comparison of two antihyperten-

observations is then compared with the distribution sives, the endpoint can be the antihypertensive activity

expected if the null hypothesis were correct (5). If this in the two treatment groups. The reduction in blood

value is greater or less than a specific limit, it is pressure is a continuous endpoint. It is also necessary to

344 Deutsches Ärzteblatt International | Dtsch Arztebl Int 2010; 107(19): 343–8

MEDICINE

mately) normally distributed or not.

If however one only considers whether the diastolic Frequently used statistical tests (modified from [3])

blood pressure falls under 90 mm Hg or not, the end- Statistical Test Description

point is then categorical. It is even binary, as there are

Fisher’s exact test Suitable for binary data in unpaired samples: the

only two possibilities. If there is a meaningful sequence 2 x 2 table is used to compare treatment effects

in the categorical endpoints, this can be described as an or the frequencies of side effects in two treat-

“ordinal endpoint.” ment groups

Chi-square test Similar to Fisher’s exact test (albeit less precise).

Paired and unpaired study designs Can also compare more than two groups or more

than two categories of the outcome variable. Pre-

A statistical test is used to compare the results of the conditions: sample size >ca. 60. Expected

endpoint under different test conditions (such as treat- number in each field ≥5.

ments). There are often two therapies.

McNemar test Preconditions similar to those for Fisher’s exact

If results can be obtained for each patient under all test, but for paired samples

experimental conditions, the study design is paired (de-

Student’s t-test Test for continuous data. Investigates whether

pendent). For example, two times of measurement may the expected values for two groups are the

be compared, or the two groups may be paired with same, assuming that the data are normally dis-

respect to other characteristics. tributed. The test can be used for paired or un-

paired groups.

Typical examples of pairs are studies performed on

one eye or on one arm of the same person. Typical Analysis of variance Test preconditions as for the unpaired t-test, for

comparison of more than two groups. The

paired designs include comparisons before and after methods of analysis of variance are also used to

treatment. “Matched pairs,” for example in case-control compare more than two paired groups.

studies, are a special case. This involves selecting per- Wilcoxon’s rank sum test (also Test for ordinal or continuous data. In contrast to

sons from one group with the same specified character- known as the unpaired Wilcoxon Student’s t-test, does not require the data to be

istics as persons in another group. The data are then no rank sum test or the Mann-Whit- normally distributed. This test too can be used

ney U test) for paired or unpaired data.

longer independent and should be treated as if they

were paired observations from one group (5). Kruskal-Wallis test Test preconditions as for the unpaired Wilcoxon

rank sum test for comparing more than two

With an unpaired or independent study design, re- groups

sults for each patient are only available under a single

Friedman test Comparison of more than two paired samples, at

set of conditions. The results of two (or more) groups least ordinally scaled data

are then compared. There may be differences in the

Log rank test Test of survival time analysis to compare two or

sizes of the groups. more independent groups

Pearson correlation test Tests whether two continuous normally dis-

Common statistical tests tributed variables exhibit linear correlation

The most important statistical tests are listed in the

Spearman correlation test Tests whether there is a monotonous relationship

Table. A distinction is always made between “categori- between two continuous, or at least ordinal, vari-

cal or continuous” and “paired or unpaired.” If the end- ables

point is continuous, normal and non-normal distribu-

tions are distinguished (Table).

The group comparison for two categorical endpoints is

illustrated here with the simplest case of a 2 x 2 table

(four field table) (Figure 1). However, the procedure is

similar for the group comparison of categorical end-

points with multiple values (Table).

● Unpaired samples:

If the frequency of success in two treatment

FIGURE 1 Test selection for

groups is to be compared, Fisher’s exact test is the

group comparison

correct statistical test, particularly with small with two categorical

samples (7). For large samples (about n >60), the endpoints;

chi-square test can also be used (Table). *1 Preconditions:

● Paired samples: sample size

One example of the use of this test would be an >ca. 60. Expected

intervention within a group at two anatomical number in each

sites, such as the implantation of two different field ≥5

sorts of IOL lenses in the right and left eyes, with

the endpoint “Operation successful: yes or no.”

The samples to be compared are paired. In such a

case, one has to perform the McNemar test (7).

Deutsches Ärzteblatt International | Dtsch Arztebl Int 2010; 107(19): 343–8 345

MEDICINE

selection for group

comparison of

a continuous

endpoint

Continuous and at least ordinally scaled variables metric tests may sink drastically if the conditions are

Figure 2 shows a decision algorithm for test selection. not fulfilled.

Normally distributed variables—parametric ● Unpaired samples:

tests: So-called parametric tests can be used if the end- The Mann-Whitney U test (also known as the

point is normally distributed. Wilcoxon rank sum test) can be used for the com-

● Unpaired samples: parison of a non-normally distributed, but at least

Where subjects in both groups are independent of ordinally scaled, parameter in two unpaired

each other (persons in first group are different samples (5). If more than two unpaired samples

from those in second group), and the parameters are to be compared, the Kruskal-Wallis test can be

are normally distributed and continuous, the un- used as a generalization of the Mann-Whitney U

paired t-test is used. If a comparison is to be made test (13).

of a normally distributed continuous parameter in ● Paired samples:

more than two independent (unpaired) groups, The Wilcoxon signed rank test can be used for the

analysis of variance (ANOVA) can be used. One comparison of two paired samples of non-

example would be a study with three or more normally distributed, but at least ordinally scaled,

treatment arms. ANOVA is a generalization of the parameters (13). Alternatively, the sign test should

unpaired t-test. ANOVA only informs you be used when the two values are only distin-

whether the groups differ, but does not say which guished on a binary scale—for example, improve-

groups. This requires methods of multiple testing ment versus deterioration (7). If more than two

(11). paired samples are being compared, the Friedman

● Paired samples: test can be used as a generalization of the sign

The paired t-test is used for normally distributed test.

continuous parameters in two paired groups. If a

normally distributed continuous parameter is Other test procedures

compared in more than two paired groups, Survival time analysis

methods based on analysis of variance are also If the point of interest is not the endpoint itself, but the

suitable. The factor describes the paired time till it is reached, survival time analysis is the most

groups—for example, more than two points of suitable procedure. This compares two or more groups

measurement in the use of a therapy. with respect to the time when an endpoint is reached

Non-normally distributed variables—non- (within the period of observation) (13). One example is

parametric tests: If the parameter of interest is not the comparison of the survival time of two groups of

normally distributed, but at least ordinally scaled, non- cancer patients given different therapies. The endpoint

parametric statistical tests are used. One of these tests here is death, although it could just as well be the

(the “rank test”) is not directly based on the observed occurrence of metastases. In contrast to the previous

values, but on the resulting rank numbers. This necessi- tests, it almost never happens that all subjects reach the

tates putting the values in order of size and giving them endpoint in survival time analysis, as the period of ob-

a running number. The test variable is then calculated servation is limited. For this reason, the data are also

from these rank numbers. If the necessary precondi- described as (right) censored, as it is still unclear when

tions are fulfilled, parametric tests are more powerful all subjects will reach the endpoint when the study

than non-parametric tests. However, the power of para- ends. The log rank test is the usual statistical test for the

346 Deutsches Ärzteblatt International | Dtsch Arztebl Int 2010; 107(19): 343–8

MEDICINE

comparison of the survival functions between two criteria such as the scale of measurement of the end-

groups. A formula is used to calculate the test variable point and its underlying distribution. We would like to

from the observed and the expected numbers of events. recommend Altman’s book (5) to the interested reader

This value can be compared with the known distribu- as a practical guide. Bortz et al. (7) present a compre-

tion which would have been expected if the null hy- hensive overview of non-parametric tests (in German).

pothesis were correct—the chi-square distribution in The selection of the statistical test before the study

this case. A p-value can thus be calculated. A rule can begins ensures that the study results do not influence

then be given for deciding for or against the null the test selection. Moreover, the necessary sample size

hypothesis. depends on the test procedure selected. Problems in

planning sample size will be discussed in more detail

Correlation analysis later in this series.

Correlation analysis examines the strength of the corre- Finally, the point must be made that a statistical test

lation between two test variables, for example, the is not necessary for every study. Statistical testing can

strength of the correlation between the body weight of a be dispensed with in purely descriptive studies (12) or

neonate and its body length. The selection of a suitable when the interrelationships are based on scientific

measure of association depends on the scale of plausibility or logical arguments. Statistical tests are

measurement and the distribution of the two par- also usually not helpful when investigating the quality

ameters. The parametric variant (Pearson correlation of a diagnostic test procedure or rater agreement (for

coefficient) exclusively tests for a linear correlation be- example, in the form of a Bland-Altman diagram) (14).

tween continuous parameters. On the other hand, the Because of the probability of error, statistical tests

non-parametric variant—the Spearman correlation co- should be used “as often as necessary, but as little as

efficient—solely tests for monotonous relationships for possible.” The risk of purely chance results is

at least ordinally scaled parameters. The advantages of especially high with multiple testing (11).

the latter are its robustness to outliers and skew dis-

tributions. Correlation coefficients measure the Conflict of interest statement

The authors declare that no conflict of interest exists according to the

strength of association and can have values between –1 guidelines of the International Committee of Medical Journal Editors.

and +1. The closer they are to 1, the stronger is the as-

sociation. A test variable and a statistical test can be Manuscript received on 14 October 2009, revised version accepted on

22 February 2010.

constructed from the correlation coefficient. The null

hypothesis to be tested is then that there is no linear (or Translated from the original German by Rodney A. Yeates, M.A., Ph.D.

monotonous) correlation.

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