Targeted test evaluation: five suggestions for refining the framework for designing diagnostic accuracy studies with clear study hypotheses

Five years ago, Korevaar and colleagues proposed a framework for designing diagnostic accuracy studies, focusing on the definition of clear study hypotheses. This proposal filled a gap and was well received by the scientific community. In this commentary, I suggest five potential refinements. They aim at increasing the flexibility of the framework while pertaining its logical consistency. The refinements address the following five topics: (1) The relationship between minimal criteria and the choice of the null hypothesis region; (2) The potential to allow compensation between sensitivity and specificity; (3) The possibility to use other pairs than sensitivity and specificity; (4) The potential phrasing as an estimation problem; (5) The advantages of directly moving to a comparative accuracy study.