The proportion of articles that reported on items related to panel constitution, information available and methods of decision making. Variation in Methodology across Studies Panel constitution. Available information for panel diagnosis. Format of presentation to the panel. Decision-making process by the panel. Table 7. Observed combinations of the decision process used in the reviewed articles.
Validity of panel diagnosis.
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Discussion Our review on the use of panel diagnoses as reference standard in diagnostic studies reveals that panel diagnoses were mainly used in studies on psychiatric, cardiovascular, or respiratory conditions. Figure 3. Flowchart of options to consider when planning and conducting panel diagnosis. Table 8. Options to consider when reporting or designing a study using a panel diagnosis as reference standard. Panel Constitution Ideally, the same members should assess all patients to increase the reproducibility of the decision process. Information Presented to the Panel The information presented to the panel, as well as the format in which it is presented, is largely determined by the study aim and context.
Decision Process A disease can be classified as present or absent or can be rated using ordered categories to represent severity or certainty of diagnosis. Validity of Panel Diagnosis Although not frequently performed, the reproducibility of a panel diagnosis is easy to assess. Supporting Information. Figure S1. Protocol S1. Data extraction form.
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Eur J Echocardiogr 8: — Am J Roentgenol — J Comput Assist Tomogr — J Card Fail — Eur J Heart Fail — Am J Emerg Med — Trevelyan J, Needham EW, Smith SC, Mattu RK Sources of diagnostic inaccuracy of conventional versus new diagnostic criteria for myocardial infarction in an unselected UK population with suspected cardiac chest pain, and investigation of independent prognostic variables. Heart — Br J Gen Pract — Ann Fam Med 9: — Respir Med — Pediatr Crit Care Med 4: — Respir Res COPD 9: — J Nucl Med — Invest Radiol — Eur J Radiol — Clin Physiol 89— Am J Gastroenterol — Chest — Crit Care R Eur Heart J — Crit Care Med — Sleep Med 81— Acad Emerg Med — Emerg Radiol 19— Eur Radiol — Clin Radiol — J Urol — The combined SIDM and Coalition to Improve Diagnosis Policy Committee members involved in drafting and finalizing this document in are listed below, with their institutional affiliations.
We gratefully acknowledge their support as well as the generosity of committee members who volunteered their time and effort.
Current Problems in Diagnostic Radiology
David E. Allen B. Elham A. Policy Roadmap for Research to Improve Diagnosis. Download Full Report. A report that assessed the value of MRS to diagnose and manage patients with space-occupying brain tumors demonstrates that there are few higher-level diagnostic test studies 8.
Table 1 shows the number of studies and patients available for systematic review at each of the 6 levels of evaluation. Among the 97 studies that met the inclusion criteria, 85 were level 1 studies that addressed technical feasibility and optimization. In contrast, only 8 level 2 studies evaluated the ability of MRS to differentiate tumors from nontumors, assign tumor grades, and detect intracranial cystic lesions or assessed the incremental value of MRS added to magnetic resonance imaging MRI.
These indications were sufficiently different that the studies could not be combined or compared. Three studies provided evidence that assessed impact on diagnostic thinking level 3 or therapeutic choice level 4. No studies assessed patient outcomes or societal impact levels 5 and 6. The case of MRS for use in diagnosis and management of brain tumors illustrates a threshold problem in systematic review of diagnostic technologies: the availability of studies providing at least level 2 evidence since diagnostic accuracy studies are the minimum level relevant to assessing the outcomes of using the test to guide patient management.
Although direct evidence is preferred, robust diagnostic accuracy studies can be used to create a causal chain for linking these studies with evidence on treatment effectiveness, thereby allowing an estimate of the effect on outcomes. The example of PET for Alzheimer disease, described later in this article, shows how decision analysis models can quantify outcomes to be expected from use of a diagnostic technology to manage treatment. The reliability of a systematic review hinges on the completeness of information used in the assessment.
Identifying all relevant data poses another challenge. Although these search strategies are useful, they do not identify grey literature publications, which by their nature are not easily accessible. Diagnostic studies with poor test performance results that are not published may lead to exaggerated estimates of a test's true sensitivity and specificity in a systematic review.
Because there are typically few studies in the categories of clinical impact, unpublished studies showing no benefit by the use of a diagnostic test have even greater potential to cause bias during a review of evidence. Of note, the problem of publication bias in randomized, controlled trials has been extensively studied, and several visual and statistical methods have been proposed to detect and correct for unpublished studies Funnel plots, which assume symmetrical scattering of studies around a common estimate, are popular for assessing publication bias in randomized, controlled trials.
Challenge: Identifying Relevant Published and Unpublished Studies
However, the appearance of the shape of the funnel plot has been shown to depend on the choices of weight and metric Without adequate empirical assessments, funnel plots are being used in systematic reviews of diagnostic tests. However, their use and interpretation should be viewed with caution. The validity of using a funnel plot to detect publication bias remains uncertain. Statistical models to detect and correct for publication bias of randomized trials also have limitations One solution to the problem of publication bias is the mandatory registration of all clinical trials before patient enrollment; for therapeutic trials, considerable progress has already been made in this area.
Such a clinical trials registry could readily apply to studies of the clinical outcomes of diagnostic tests Diagnostic test evaluations often have methodologic weaknesses Of the 8 diagnostic accuracy studies of MRS, half had small sample sizes. Of the larger studies, all had limitations related to patient selection or potential for observer bias. Test accuracy studies often have important biases, which may result in unreliable estimates of the accuracy of a diagnostic test Several proposals have been advanced to assess the quality of a study evaluating diagnostic accuracy Partly because of the lack of a true reference standard, there is no consensus for a single approach to assessing study quality The lack of consistent relationships between specific quality elements and the magnitude of outcomes complicates the task of assessing quality 27, In addition, quality is assessed on the basis of reported information that does not necessarily reflect how the study was actually performed and analyzed.
The Standards for Reporting of Diagnostic Accuracy STARD group recently published a item checklist as a guide to improve the quality of reporting all aspects of a diagnostic study However, many items in the checklist are included in a recently developed tool for quality assessment of diagnostic accuracy studies the QUADAS tool. The QUADAS tool consists of 14 items that cover patient spectrum, reference standard, disease progression bias, verification and review bias, clinical review bias, incorporation bias, test execution, study withdrawals, and intermediate results 28, Studies beyond the level of technical feasibility must include both diseased and nondiseased individuals who reflect the use of the diagnostic technologies in actual clinical settings.
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Because of the need to understand the relationship between test sensitivity and specificity, a study that reports only sensitivity that is, evaluation of the test only in a diseased population or only specificity that is, evaluation of the test only in a healthy population results cannot be used for this evaluation. In this section, we base our discussion on the evidence report on evaluating diagnostic technologies for acute cardiac ischemia in the emergency department 7.
When the spectrum of disease ranges widely within a diseased population, the interpretation of results in a diagnostic accuracy study may be affected if study participants possess only certain characteristics of the diseased population 15, For example, patients in cardiac care units are more likely to have acute cardiac ischemia than patients in the emergency department.
When patients with more severe illness are analyzed, the false-positive rate is reduced and sensitivity is overestimated. For example, biomarkers may have high sensitivity when used in patients with acute myocardial infarction in a cardiac care unit but may perform poorly in an emergency department because of their inability to detect unstable angina pectoris.
Table 2 shows the distribution of studies according to hospital settings and inclusion criteria for presenting symptoms used in each of the studies. Although there were a total of studies, the number of studies available for analysis at each hospital setting and for each inclusion criteria definition is limited. If we apply a strict criterion of accepting only studies performed in the emergency department and on patients with the most inclusive definition of acute cardiac ischemia category I in the table , only 13 studies are available.
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Furthermore, some studies used acute cardiac ischemia as the outcome of interest and some used acute myocardial infarction, further reducing the number of studies available for a specific assessment. As shown by the small numbers in some cells of the table, the information available from all studies using the 21 diagnostic technologies meeting the criteria is lacking for certain combinations of patients and settings.
The heterogeneity of study populations makes synthesizing study results difficult. Used in conjunction within the 6-level framework, this scheme of categorizing the population and settings into similar groups greatly facilitates study comparison and interpretation of results. Other publications have described the methods for meta-analysis of diagnostic test accuracy We discuss the basic challenges of applying these methods and interpreting their results here.
Figures 1 and 2 illustrate examples of results obtained from 2 common methods. Figure 1. Meta-analysis of studies evaluating the use of a single creatine kinase measurement to diagnose acute myocardial infarction in the emergency department. Figure 2. Summary receiver-operating characteristics curve analysis of studies evaluating the use of a single creatine kinase measurement to diagnose acute myocardial infarction in the emergency department. Diagnostic test results are often reported as a numeric quantity on a continuous scale for example, troponin level but are then used as a binary decision tool by defining a threshold above which the test result is positive and below which it is negative.
Changing this threshold changes both the sensitivity and specificity of the test. This fundamental bivariate structure poses a challenge for constructing a single-number summary to describe test performance. Table 3 summarizes common single-number measures used to describe test performance. Only the last 4 combine information about both sensitivity and specificity. This can be illustrated by the different ROC curves that each measure implies. A constant sensitivity implies a horizontal line, a constant specificity implies a vertical line, and a constant likelihood ratio also implies a linear relationship between sensitivity and specificity.
The odds ratio, on the other hand, describes a curve symmetrical about the line where sensitivity equals specificity.