Medical educators attempt to create reliable and valid tests and questionnaires in order to enhance the accuracy of their assessment and evaluations. Validity and reliability are two fundamental elements in the evaluation of a measurement instrument. Instruments can be conventional knowledge, skill or attitude tests, clinical simulations or survey questionnaires. Instruments can measure concepts, psychomotor skills or affective values. Validity is concerned with the extent to which an instrument measures what it is intended to measure. Reliability is concerned with the ability of an instrument to measure consistently.1 It should be noted that the reliability of an instrument is closely associated with its validity. An instrument cannot be valid unless it is reliable. However, the reliability of an instrument does not depend on its validity.2 It is possible to objectively measure the reliability of an instrument and in this paper we explain the meaning of Cronbach’s alpha, the most widely used objective measure of reliability.

Calculating alpha has become common practice in medical education research when multiple-item measures of a concept or construct are employed. This is because it is easier to use in comparison to other estimates (e.g. test-retest reliability estimates)3 as it only requires one test administration. However, in spite of the widespread use of alpha in the literature the meaning, proper use and interpretation of alpha is not clearly understood. 2, 4, 5 We feel it is important, therefore, to further explain the underlying assumptions behind alpha in order to promote its more effective use. It should be emphasised that the purpose of this brief overview is just to focus on Cronbach’s alpha as an index of reliability. Alternative methods of measuring reliability based on other psychometric methods, such as generalisability theory or item-response theory, can be used for monitoring and improving the quality of OSCE examinations 6-10, but will not be discussed here.

What is Cronbach alpha?
Alpha was developed by Lee Cronbach in 195111 to provide a measure of the internal consistency of a test or scale; it is expressed as a number between 0 and 1. Internal consistency describes the extent to which all the items in a test measure the same concept or construct and hence it is connected to the inter-relatedness of the items within the test. Internal consistency should be determined before a test can be employed for research or examination purposes to ensure validity. In addition, reliability estimates show the amount of measurement error in a test. Put simply, this interpretation of reliability is the correlation of test with itself. Squaring this correlation and subtracting from 1.00 produces the index of measurement error. For example, if a test has a reliability of 0.80, there is 0.36 error variance (random error) in the scores (0.80×0.80 = 0.64; 1.00 – 0.64 = 0.36).12 As the estimate of reliability increases, the fraction of a test score that is attributable to error will decrease.2 It is of note that the reliability of a test reveals the effect of measurement error on the observed score of a student cohort rather than on an individual student. To calculate the effect of measurement error on the observed score of an individual student, the standard error of measurement must be calculated (SEM).13

If the items in a test are correlated to each other, the value of alpha is increased. However, a high coefficient alpha does not always mean a high degree of internal consistency. This is because alpha is also affected by the length of the test. If the test length is too short, the value of alpha is reduced.2, 14 Thus, to increase alpha, more related items testing the same concept should be added to the test. It is also important to note that alpha is a property of the scores on a test from a specific sample of testees. Therefore investigators should not rely on published alpha estimates and should measure alpha each time the test is administered.14


Use of Cronbach’s alpha
Improper use of alpha can lead to situations in which either a test or scale is wrongly discarded or the test is criticised for not generating trustworthy results. To avoid this situation an understanding of the associated concepts of internal consistency, homogeneity or unidimensionality can help to improve the use of alpha. Internal consistency is concerned with the interrelatedness of a sample of test items, whereas homogeneity refers to unidimensionality. A measure is said to be unidimensional if its items measure a single latent trait or construct. Internal consistency is a necessary but not sufficient condition for measuring homogeneity or unidimensionality in a sample of test items. 5, 15 Fundamentally, the concept of reliability assumes that unidimensionality exists in a sample of test items16 and if this assumption is violated it does cause a major underestimate of reliability. It has been well documented that a multidimensional test does not necessary have a lower alpha than a unidimensional test. Thus a more rigorous view of alpha is that it cannot simply be interpreted as an index for the internal consistency of a test. 5, 15, 17

Factor Analysis can be used to identify the dimensions of a test.18 Other reliable techniques have been used and we encourage the reader to consult the paper “Applied Dimensionality and Test Structure Assessment with the START-M Mathematics Test” and to compare methods for assessing the dimensionality and underlying structure of a test.19

Alpha, therefore, does not simply measure the unidimensionality of a set of items, but can be used to confirm whether or not a sample of items is actually unidimensional.5 On the other hand if a test has more than one concept or construct, it may not make sense to report alpha for the test as a whole as the larger number of questions will inevitable inflate the value of alpha. In principle therefore, alpha should be calculated for each of the concepts rather than for the entire test or scale. 2, 3 The implication for a summative examination containing heterogeneous, case-based questions is that alpha should be calculated for each case.

More importantly, alpha is grounded in the ‘tau equivalent model’ which assumes that each test item measures the same latent trait on the same scale. Therefore, if multiple factors/traits underlie the items on a scale, as revealed by Factor Analysis, this assumption is violated and alpha underestimates the reliability of the test.17 If the number of test items is too small it will also violate the assumption of tau-equivalence and will underestimate reliability.20 When test items meet the assumptions of the tau-equivalent model, alpha approaches a better estimate of reliability. In practice, Cronbach’s alpha is a lower-bound estimate of reliability because heterogeneous test items would violate the assumptions of the tau-equivalent model.5 If the calculation of “standardised item alpha” in SPSS is higher than “Cronbach’s alpha”, a further examination of the tau-equivalent measurement in the data may be essential.


Numerical values of alpha
As pointed out earlier, the number of test items, item inter-relatedness and dimensionality affect the value of alpha.5 There are different reports about the acceptable values of alpha, ranging from 0.70 to 0.95. 2, 21, 22 A low value of alpha could be due to a low number of questions, poor inter-relatedness between items or heterogeneous constructs. For example if a low alpha is due to poor correlation between items then some should be revised or discarded. The easiest method to find them is to compute the correlation of each test item with the total score test; items with low correlations (approaching zero) are deleted. If alpha is too high it may suggest that some items are redundant as they are testing the same question but in a different guise. A maximum alpha value of 0.90 has been recommended.14


Summary
High quality tests are important to evaluate the reliability of data supplied in an examination or a research study. Alpha is a commonly employed index of test reliability. Alpha is affected by the test length and dimensionality. Alpha as an index of reliability should follow the assumptions of the essentially tau-equivalent approach. A low alpha appears if these assumptions are not meet. Alpha does not simply measure test homogeneity or unidimensionality as test reliability is a function of test length. A longer test increases the reliability of a test regardless of whether the test is homogenous or not. A high value of alpha (> 0.90) may suggest redundancies and show that the test length should be shortened.

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Making sense of Cronbach's alpha

Relationship between bond-strength tests and clinical outcomes

Objective As part of the Multisite Research Diagnostic Criteria For Temporomandibular Disorders (RDC/TMD) Validation Project, comprehensive temporomandibular joint diagnostic criteria were developed for image analysis using panoramic radiography, magnetic resonance imaging (MRI), and computerized tomography (CT). Study design Interexaminer reliability was estimated using the kappa (κ) statistic, and agreement between rater pairs was characterized by overall, positive, and negative percent agreement. Computerized tomography was the reference standard for assessing validity of other imaging modalities for detecting osteoarthritis (OA). Results For the radiologic diagnosis of OA, reliability of the 3 examiners was poor for panoramic radiography (κ = 0.16), fair for MRI (κ = 0.46), and close to the threshold for excellent for CT (κ = 0.71). Using MRI, reliability was excellent for diagnosing disc displacements (DD) with reduction (κ = 0.78) and for DD without reduction (κ = 0.94) and good for effusion (κ = 0.64). Overall percent agreement for pairwise ratings was ≥82% for all conditions. Positive percent agreement for diagnosing OA was 19% for panoramic radiography, 59% for MRI, and 84% for CT. Using MRI, positive percent agreement for diagnoses of any DD was 95% and of effusion was 81%. Negative percent agreement was ≥88% for all conditions. Compared with CT, panoramic radiography and MRI had poor and marginal sensitivity, respectively, but excellent specificity in detecting OA. Conclusion Comprehensive image analysis criteria for the RDC/TMD Validation Project were developed, which can reliably be used for assessing OA using CT and for disc position and effusion using MRI.

/pdf/research-diagnostic-criteria-for-temporomandibular-disorders-14obpt1err.pdf

Research diagnostic criteria for temporomandibular disorders (RDC/TMD): development of image analysis criteria and examiner reliability for image analysis.

Calcium silicate bioactive cements: Biological perspectives and clinical applications.

Han L, Okiji T. Uptake of calcium and silicon released from calcium silicate–based endodontic materials into root canal dentine. International Endodontic Journal. Aim To compare Biodentine and White ProRoot mineral trioxide aggregate (MTA) with regard to Ca and Si uptake by adjacent root canal dentine in the presence of phosphate-buffered saline (PBS). Methodology Root canals of bovine incisor root segments were instrumented, filled with either Biodentine or MTA (n = 20 each) and then immersed in Ca-and Mg-free PBS for 1, 7, 30 or 90 days (n =5 each). Unfilled, unimmersed dentine specimens (n =5 ) served as controls. The specimens were sectioned longitudinally, and the ultrastructure of the dentine‐ material interface and the elemental composition/ distribution in the material‐adjacent dentine were analysed using a wavelength-dispersive X-ray spectroscopy electron probe microanalyser with image observation function. Data were statistically analyzed using one-way anova and Tukey’s honestly significant difference test or the Mann‐Whitney U-test. Results Along the material‐dentine interface, both materials formed a tag-like structure that was composed of either Ca- and P-rich crystalline deposits or the material itself. The width of a Ca- and Si-rich layer detected along the dentine layer of the material‐ dentine interface showed increases over time. The Caand Si-rich layer width was significantly larger (P < 0.05) in Biodentine than MTA at 30 and 90 days. Conclusions Both Biodentine and MTA caused the uptake of Ca and Si in the adjacent root canal dentine in the presence of PBS. The dentine element uptake was more prominent for Biodentine than MTA.

/pdf/uptake-of-calcium-and-silicon-released-from-calcium-silicate-5d684qe1r1.pdf

Uptake of calcium and silicon released from calcium silicate-based endodontic materials into root canal dentine

Summary Aim The aim of this retrospective study was to investigate whether radical (segmental resection) or conservative (marginal) resection of mandibular bone influenced patients, survival. Patients and methods A series of 136 patients selected for partial mandibular resection for the treatment of squamous cell carcinomas of the lower oral cavity was evaluated retrospectively. Fifty-four patients underwent marginal and 82 cases segmental resection of the mandible. The mean follow-up periods were 91.1±30.1 months and 91.5±26.2 months, respectively. Data was extracted from the patient records and transferred into a database for statistical evaluation. Results Mean survival was 63.0±35.3 months for marginal and 53.1±32.3 months for segmental resection. The overall survival rate was analysed according to Kaplan–Meier and the test of significance (Log Rank) which yielded no statistically significant difference in the survival rate between both groups ( p =0.1119). Numbers of recurrences, second primaries, metastases and/or postoperative complications were similar in both groups, i.e. no statistically significant differences were observed (ANOVA, Post-hoc Scheffe test). Conclusion In cases with an indication for bone resection, marginal resection may achieve satisfactory control and is as effective as segmental resection.

Influence of marginal and segmental mandibular resection on the survival rate in patients with squamous cell carcinoma of the inferior parts of the oral cavity.

Objective:The composition of the oral microbiome differs distinctively between subjects with and without active caries. Still, caries research has mainly been focused on states of disease; aspects ...

https://tandfonline.com/doi/pdf/10.1080/20002297.2019.1633194

Bacterial biofilm composition in healthy subjects with and without caries experience.

Introduction: An objective structured clinical examination (OSCE) has been implemented in preclinical dentistry. It was taken at an early stage (propaedeutics course). The objectives of this study were to evaluate the reliability, validity, and feasibility of the examination, and the effect of circuit number on OSCE score.



Methods:  The OSCE was designed by an expert committee on the basis of pre-reviewed blueprints and checklists. Eleven stations formed an interdisciplinary circuit. Six groups of students (n = 62) passed sequentially round the same circuit. Statistical analysis was performed by using SPSS. Reliability was determined by measurement of internal consistency (Cronbach’s α, Guttman’s λ2), standard error of measurement (SEM) (comprising generalisability index α, dependability index ϕ and pass 150;fail reliability pc), consistency coefficient κ, item 150;scale correlation (Pearson correlation), and, because the unidimensionality of the stations could not be assumed, factor analysis including varimax rotation. Convergent validity (Pearson correlation, t-test), and predictive validity for future preclinical courses and the final preclinical examination were assessed by analysis of variance (ANOVA). The effect of the circuit number on score improvement was calculated, including a correction for the general competence of the students (ANOVA). Cost was calculated on the basis of the time invested.



Results:  Fifty-three out of sixty-two students passed the OSCE (mean score: 67%, SD 7.7, range, 47–81). Scores for each station correlated significantly with total scores (r = 0.35–0.54, P < 0.01). For internal consistency, α = 0.75 (relative SEM 3.8) and λ2 = 0.766. The dependability index was ϕ = 0.694 (absolute SEM 4.4), pc = 0.89 and κ = 0.61. Factor analysis yielded two components: dental-materials-oriented stations and all other stations (explained variance 43%). Scores correlated significantly with success in passing practical tests (i.e. performing dental procedures under examination conditions) (known group validity, P < 0.01) and with scores for subsequent courses and the final preclinical examination (Physikum) (predictive validity, P < 0.001). Later groups performed 4% better on average (CI 95%: 1.2–6.8%; P < 0.01). The cost was 181 Euro per student.



Conclusions:  The OSCE is reliable and valid in the context of preclinical dentistry. The cost is substantial. The problem of improvement of students' results with ascending circuit number has to be addressed.

Analysis of quality and feasibility of an objective structured clinical examination (OSCE) in preclinical dental education.

Relationship between microtensile bond strength and nanoleakage at the composite-dentin interface

PURPOSE To obtain survival data on 32 fiber-reinforced fixed dental prostheses which were inserted in our department and to rate the quality of these restorations on the basis of esthetic, biological, and functional parameters. MATERIALS AND METHODS Thirty-two patients with fiber-reinforced fixed dental prostheses were included in the study. The fiber frameworks were made of a polymer-monomer-preimpregnated continuous unidirectional glass fiber material. The survival times, failure events, and clinical parameters were recorded. Restorations in function without previous failure were classified as "Overall Survival". The classification "Functional Survival" was assigned in the event of minor failure and subsequent repair. Loss of the restoration was regarded as "Failure". The quality rating was performed using modified USHPS/Ryge criteria. RESULTS The follow-up interval ranged from 2 to 64 months with a median follow-up time of 18.2 months. Twenty-four restorations were classified as "Overall Survival", seven were classified as "Functional Survival", and one was classified as "Failure". The overall survival at the median follow-up time was 74.4%. For the majority, the quality rating (USHPS/Ryge criteria) yielded clinically excellent results in all categories. No restoration was rated as insufficient or poor. CONCLUSION Fiber-reinforced composite fixed dental prostheses provide sufficient stability and very good esthetic, biological, and functional performance in the case of specific clinical indications.

Diana Wolff

Papers

Influence of marginal and segmental mandibular resection on the survival rate in patients with squamous cell carcinoma of the inferior parts of the oral cavity.

Bacterial biofilm composition in healthy subjects with and without caries experience.

Analysis of quality and feasibility of an objective structured clinical examination (OSCE) in preclinical dental education.

Relationship between microtensile bond strength and nanoleakage at the composite-dentin interface

Fiber-reinforced composite fixed dental prostheses: a retrospective clinical examination.