A systematic review of brief screeners for suicidal behaviour in primary care

Abstract Background As primary contacts, general practitioners can play a pivotal role in identifying suicidal behaviour in their patients. Therefore, actively screening patients at risk should be an integral part of primary care services. We summarized the available studies reporting diagnostic accuracy of short screening instruments for suicidal behaviour in primary care or the general population in a narrative synthesis. A brief instrument could improve the identification of vulnerable patients and their subsequent referral to mental health specialist. Methods: The following databases MEDLINE, EMBASE, PsychINFO, PSYNDEX, and Cochrane Library were searched in January 2019 without any time constraints. Risk of bias and applicability concerns were assessed using the QUADAS-2 tool. The certainty of evidence was rated via GRADEpro. The authors followed the PRISMA extensions for Diagnostic Test Accuracy Studies. Results Six relevant studies fulfilled all criteria and were included. Each index test was only assessed in a single study. The studies each used different reference standards. Target conditions defined across the different studies were suicidal ideation, suicide plan, suicide attempt, and suicidal behaviour in general. The diagnostic accuracy measurements sensitivity and specificity had a wide range (sensitivity: 26% - 100%, specificity: 64% - 99%). Risk of bias was rated moderate and concerns regarding applicability acceptable. A required sensitivity of at least 80% and specificity of 50% with a moderate to high GRADE rating was achieved by six of nine index tests. Conclusions Overall, only a few studies assessed screening instruments for suicidal behaviour in primary care or the general population. The identified studies were heterogeneous regarding sample size, index test, and reference standard. Since each index test was only evaluated in one study, their interpretability is limited. No uniform gold standard was found, as the studies identified used different reference standards. Although there are other promising short questionnaires, the majority has not yet been evaluated in primary care setting or the general population with regard to their diagnostic accuracy. A final assessment should always be based on the clinical judgement of the attending physician. Registration The study protocol was registered at PROSPERO (ID: CRD42019122173).

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A systematic review of brief screeners for suicidal behaviour in primary care

10.21203/rs.2.14068/v2 ◽

2019 ◽

Author(s):

Karoline Lukaschek ◽

Milena Frank ◽

Kathrin Halfter ◽

Antonius Schneider ◽

Jochen Gensichen

Keyword(s):

Primary Care ◽

Suicidal Ideation ◽

Diagnostic Accuracy ◽

Diagnostic Test ◽

Suicidal Behaviour ◽

Risk Of Bias ◽

Diagnostic Test Accuracy ◽

Cochrane Library ◽

Test Accuracy ◽

Index Tests

Abstract Background: As primary contacts, general practitioners can play a pivotal role in identifying suicidal behaviour in their patients. A brief instrument could help in identifying vulnerable patients. We summarized the available studies reporting diagnostic accuracy of short screening instruments for suicidal behaviour in primary care or the general population in a narrative synthesis. Methods: The databases MEDLINE, EMBASE, PsychINFO, PSYNDEX, and Cochrane Library were searched in January 2019 without any time constraints. Risk of bias and applicability concerns were assessed using the QUADAS-2 tool. The certainty of evidence was rated via GRADEpro. The authors followed the PRISMA extensions for Diagnostic Test Accuracy Studies. Results: We identified a total of 9 969 studies with our search strategy. After the selection process, six relevant studies fulfilled all criteria and were included. They used the following index tests: Kessler Psychological Distress Scale, Suicidal Ideation Screening Questionnaire, Suicidal Ideation Attributes Scale, Gate question suicide attempt, Gate question suicidal ideation, Feeling suicidal, Wishing you were dead, Thoughts of death and Patient-Health-Questionaire-9 - item 9. The diagnostic accuracy measurements sensitivity and specificity had a wide range (sensitivity: 26% - 100%, specificity: 64% - 99%). Risk of bias was rated moderate and concerns regarding applicability acceptable. A required sensitivity of at least 80% and specificity of 50% with a moderate to high GRADE rating was achieved by six of nine index tests. Conclusions: The identified studies were heterogeneous regarding sample size, index test and reference standard. Even though screening of suicidal behaviour in primary care is already recommended by several guidelines, there are only few screeners in primary care that have been examined regarding their diagnostic accuracy. Although they can assist GPs in their judgement of suicidal behaviour of patients at risk, the final assessment is always based on the clinical judgement of the attending physician. Further diagnostic test accuracy studies of promising short questionnaires are needed. Registration: The study protocol was registered at PROSPERO (ID: CRD42019122173).

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A Systematic Review of Short Screening Instruments for Suicidal Behaviour in Primary Care

Journal of Family Medicine ◽

10.26420/jfammed.2021.1246 ◽

2021 ◽

Vol 8 (2) ◽

Author(s):

Lukaschek K ◽

◽

Frank M ◽

Gensichen J ◽

Halfter K ◽

...

Keyword(s):

Primary Care ◽

Negative Predictive Value ◽

Predictive Value ◽

Time Management ◽

Suicidal Behaviour ◽

Risk Of Bias ◽

Initial Assessment ◽

Cochrane Library ◽

Screening Instruments ◽

Brief Screening

Background: Due to strict time management General Practitioners (GPs) prefer short instruments when identifying suicidal behaviour in their patients. We summarize the available studies reporting diagnostic accuracy of brief instruments for suicidal behaviour in primary care. Method: Databases MEDLINE, EMBASE, PsychINFO, PSYNDEX, and Cochrane Library were searched without any time constraints. Risk of bias and applicability concerns were assessed using the QUADAS-2 tool. The certainty of evidence was rated via GRADEpro. We included studies on primary care patients or participants from the general population. Suicidal behaviour was the defined target condition. With respect to the applicability in a primary care setting we included only studies assessing brief screening instruments; a brief instrument was defined as having no more than twelve items. We assessed sensitivity, specificity, and positive and negative predictive value. Results: A total of 9,969 studies was identified; of those, six fulfilled all strong criteria and were included. The range of sensitivity was 0.26-1.00, specificity was 0.64-0.99, positive predictive value 0.06-0.91, negative predictive value 0.86-1.00. Risk of bias was rated moderate and concerns regarding applicability acceptable. A required sensitivity of at least 0.80 and specificity of 0.50 with a moderate to high GRADE rating was achieved by six of nine index tests. Conclusions: Brief screening instruments can support ruling-out suicidality, but are less suitable for ruling-in. They may support GPs in an initial assessment, but in case of a positive test result, a valid diagnostic assessment should be done by a structured clinical interview.

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The utility of diagnostic selective nerve root blocks in the management of patients with lumbar radiculopathy: a systematic review

BMJ Open ◽

10.1136/bmjopen-2018-025790 ◽

2019 ◽

Vol 9 (4) ◽

pp. e025790 ◽

Cited By ~ 4

Author(s):

Rebecca Beynon ◽

Martha Maria Christine Elwenspoek ◽

Athena Sheppard ◽

John Nicholas Higgins ◽

Angelos G Kolias ◽

...

Keyword(s):

Systematic Review ◽

Diagnostic Accuracy ◽

Nerve Root ◽

Risk Of Bias ◽

Decompression Surgery ◽

Test Accuracy ◽

Index Test ◽

Lumbar Radiculopathy ◽

Reference Standard ◽

Nerve Root Blocks

ObjectiveLumbar radiculopathy (LR) often manifests as pain in the lower back radiating into one leg (sciatica). Unsuccessful back surgery is associated with significant healthcare costs and risks to patients. This review aims to examine the diagnostic accuracy of selective nerve root blocks (SNRBs) to identify patients most likely to benefit from lumbar decompression surgery.DesignSystematic review of diagnostic test accuracy studies.Eligibility criteriaPrimary research articles using a patient population with low back pain and symptoms in the leg, SNRB administered under radiological guidance as index test, and any reported reference standard for the diagnosis of LR.Information sourcesMEDLINE (Ovid), MEDLINE In-Process & Other Non-Indexed Citations, EMBASE, Science Citation Index, Biosis, LILACS, Dissertation abstracts and National Technical Information Service from inception to 2018.MethodsRisk of bias and applicability was assessed using the QUADAS-2 tool. We performed random-effects logistic regression to meta-analyse studies grouped by reference standard.Results6 studies (341 patients) were included in this review. All studies were judged at high risk of bias. There was substantial heterogeneity across studies in sensitivity (range 57%–100%) and specificity (10%–86%) estimates. Four studies were diagnostic cohort studies that used either intraoperative findings during surgery (pooled sensitivity: 93.5% [95% CI 84.0 to 97.6]; specificity: 50.0% [16.8 to 83.2]) or ‘outcome following surgery’ as the reference standard (pooled sensitivity: 90.9% [83.1 to 95.3]; specificity 22.0% [7.4 to 49.9]). Two studies had a within-patient case-control study design, but results were not pooled because different types of control injections were used.ConclusionsWe found limited evidence which was of low methodological quality indicating that the diagnostic accuracy of SNRB is uncertain and that specificity in particular may be low. SNRB is a safe test with a low risk of clinically significant complications, but it remains unclear whether the additional diagnostic information it provides justifies the cost of the test.

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A Systematic Review of the Current State and Validity of Digital Assessment Tools for Psychiatry (Preprint)

10.2196/preprints.32824 ◽

2021 ◽

Author(s):

Nayra Anna Martin-Key ◽

Benedetta Spadaro ◽

Erin Funnell ◽

Eleanor Jane Barker ◽

Thea Sofie Schei ◽

...

Keyword(s):

Mental Health ◽

Systematic Review ◽

Depressive Disorder ◽

Diagnostic Accuracy ◽

Mental Healthcare ◽

Risk Of Bias ◽

Assessment Tools ◽

Cochrane Library ◽

Digital Assessment ◽

Current State

BACKGROUND Given the role digital technologies are likely to play in the future of mental healthcare, there is a need for a comprehensive appraisal of the current state and validity (i.e., screening/diagnostic accuracy) of digital mental health assessments. OBJECTIVE To explore the current state and validity of question-and-answer-based digital tools for diagnosing and screening psychiatric conditions in adults. METHODS This systematic review was based on the Population, Intervention, Comparison, and Outcome (PICO) framework and was carried out in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. MEDLINE, Embase, Cochrane Library, ASSIA, Web of Science Core Collection, CINAHL, and PsycINFO were systematically searched for articles published between 2005 and 2020. A descriptive evaluation of the study characteristics and digital solutions and a quantitative appraisal of the screening/diagnostic accuracy of the included tools was conducted. Risk of bias and applicability were assessed using the Revised Tool for the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) guidelines. RESULTS A total of 25 studies met the inclusion criteria, with the most frequently evaluated conditions encompassing generalized anxiety disorder (GAD), major depressive disorder (MDD), and any depressive disorder. The majority of the studies employed digitized versions of existing pen-and-paper questionnaires, with findings revealing poor to excellent screening/diagnostic accuracy (sensitivity = 0.36-1.00, specificity = 0.37-1.00, AUC = 0.57-0.98) and a high risk of bias for most of the included studies. CONCLUSIONS The current state of the field of digital mental health tools is in its early stages and high-quality evidence is lacking. INTERNATIONAL REGISTERED REPORT RR2-10.2196/25382

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Risk of bias and limits of reporting in diagnostic accuracy studies for commercial point-of-care tests for respiratory pathogens

Epidemiology and Infection ◽

10.1017/s0950268818000596 ◽

2018 ◽

Vol 146 (6) ◽

pp. 747-756

Author(s):

J.M. Hughes ◽

C. Penney ◽

S. Boyd ◽

P. Daley

Keyword(s):

Diagnostic Accuracy ◽

Test Performance ◽

Point Of Care ◽

Risk Of Bias ◽

Financial Impact ◽

Test Accuracy ◽

Respiratory Pathogens ◽

Study Results ◽

Group A ◽

Point Of Care Tests

AbstractCommercial point-of-care (POC) diagnostic tests for Group A Streptococcus, Streptococcus pneumoniae, and influenza virus have large potential diagnostic and financial impact. Many published reports on test performance, often funded by diagnostics companies, are prone to bias. The Standards for Reporting of Diagnostic Accuracy (STARD 2015) are a protocol to encourage accurate, transparent reporting. The Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool evaluates risk of bias and transportability of results. We used these tools to evaluate diagnostic test accuracy studies of POC studies for three respiratory pathogens. For the 96 studies analysed, compliance was <25% for 14/34 STARD 2015 standards, and 3/7 QUADAS-2 domains showed a high risk of bias. All reports lacked reporting of at least one criterion. These biases should be considered in the interpretation of study results.

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The diagnostic accuracy of isothermal nucleic acid point-of-care tests for human coronaviruses: A systematic review and meta-analysis

Scientific Reports ◽

10.1038/s41598-020-79237-7 ◽

2020 ◽

Vol 10 (1) ◽

Cited By ~ 1

Author(s):

Pakpoom Subsoontorn ◽

Manupat Lohitnavy ◽

Chuenjid Kongkaew

Keyword(s):

Systematic Review ◽

Diagnostic Accuracy ◽

Diagnostic Test ◽

Point Of Care ◽

Meta Analysis ◽

Isothermal Amplification ◽

Diagnostic Test Accuracy ◽

Test Accuracy ◽

Index Test ◽

Point Of Care Tests

AbstractMany recent studies reported coronavirus point-of-care tests (POCTs) based on isothermal amplification. However, the performances of these tests have not been systematically evaluated. Cochrane Handbook for Systematic Reviews of Diagnostic Test Accuracy was used as a guideline for conducting this systematic review. We searched peer-reviewed and preprint articles in PubMed, BioRxiv and MedRxiv up to 28 September 2020 to identify studies that provide data to calculate sensitivity, specificity and diagnostic odds ratio (DOR). Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2) was applied for assessing quality of included studies and Preferred Reporting Items for a Systematic Review and Meta-analysis of Diagnostic Test Accuracy Studies (PRISMA-DTA) was followed for reporting. We included 81 studies from 65 research articles on POCTs of SARS, MERS and COVID-19. Most studies had high risk of patient selection and index test bias but low risk in other domains. Diagnostic specificities were high (> 0.95) for included studies while sensitivities varied depending on type of assays and sample used. Most studies (n = 51) used reverse transcription loop-mediated isothermal amplification (RT-LAMP) to diagnose coronaviruses. RT-LAMP of RNA purified from COVID-19 patient samples had pooled sensitivity at 0.94 (95% CI: 0.90–0.96). RT-LAMP of crude samples had substantially lower sensitivity at 0.78 (95% CI: 0.65–0.87). Abbott ID Now performance was similar to RT-LAMP of crude samples. Diagnostic performances by CRISPR and RT-LAMP on purified RNA were similar. Other diagnostic platforms including RT- recombinase assisted amplification (RT-RAA) and SAMBA-II also offered high sensitivity (> 0.95). Future studies should focus on the use of un-bias patient cohorts, double-blinded index test and detection assays that do not require RNA extraction.

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Weight loss as a predictor of cancer in primary care: a systematic review and meta-analysis

British Journal of General Practice ◽

10.3399/bjgp18x695801 ◽

2018 ◽

Vol 68 (670) ◽

pp. e311-e322 ◽

Cited By ~ 11

Author(s):

Brian D Nicholson ◽

William Hamilton ◽

Jack O’Sullivan ◽

Paul Aveyard ◽

FD Richard Hobbs

Keyword(s):

Primary Care ◽

Weight Loss ◽

Meta Analysis ◽

Age Groups ◽

Biliary Tree ◽

Clinical Feature ◽

Test Accuracy ◽

Index Test ◽

Likelihood Ratios ◽

Predictive Values

BackgroundWeight loss is a non-specific cancer symptom for which there are no clinical guidelines about investigation in primary care.AimTo summarise the available evidence on weight loss as a clinical feature of cancer in patients presenting to primary care.Design and settingA diagnostic test accuracy review and meta-analysis.MethodStudies reporting 2 × 2 diagnostic accuracy data for weight loss (index test) in adults presenting to primary care and a subsequent diagnosis of cancer (reference standard) were included. QUADAS-2 was used to assess study quality. Sensitivity, specificity, positive likelihood ratios, and positive predictive values were calculated, and a bivariate meta-analysis performed.ResultsA total of 25 studies were included, with 23 (92%) using primary care records. Of these, 20 (80%) defined weight loss as a physician’s coding of the symptom; the remainder collected data directly. One defined unexplained weight loss using objective measurements. Positive associations between weight loss and cancer were found for 10 cancer sites: prostate, colorectal, lung, gastro-oesophageal, pancreatic, non-Hodgkin’s lymphoma, ovarian, myeloma, renal tract, and biliary tree. Sensitivity ranged from 2% to 47%, and specificity from 92% to 99%, across cancer sites. The positive predictive value for cancer in male and female patients with weight loss for all age groups ≥60 years exceeded the 3% risk threshold that current UK guidance proposes for further investigation.ConclusionA primary care clinician’s decision to code for weight loss is highly predictive of cancer. For such patients, urgent referral pathways are justified to investigate for cancer across multiple sites.

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Diagnostic performance of the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation at estimating glomerular filtration rate in adults with diabetes mellitus: a systematic review and meta-analysis protocol

BMJ Open ◽

10.1136/bmjopen-2019-031558 ◽

2019 ◽

Vol 9 (8) ◽

pp. e031558 ◽

Cited By ~ 6

Author(s):

Neda Zafari ◽

Leonid Churilov ◽

Richard J MacIsaac ◽

Niloufar Torkamani ◽

Helen Baxter ◽

...

Keyword(s):

Systematic Review ◽

Chronic Kidney Disease ◽

Glomerular Filtration Rate ◽

Kidney Disease ◽

Diagnostic Accuracy ◽

Glomerular Filtration ◽

Filtration Rate ◽

Risk Of Bias ◽

Index Test ◽

Disease Epidemiology

IntroductionTimely detection leading to the implementation of reno-protective measures reduces the progression of diabetic kidney disease. Estimated glomerular filtration rate (eGFR) is a major surrogate of kidney function. The Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) Equation is a tool to estimate GFR. This protocol outlines a systematic-review, assessing the diagnostic accuracy of the CKD-EPI equation in adults with diabetes.Methods and analysisMEDLINE, Embase, Cochrane Central Register of Controlled Trials and grey literature will be searched for publications in English, Farsi, Dutch and Chinese from 2009 (when CKD-EPI was first introduced) to January 2019. Bridging searches will be conducted to capture literature published from January 2019 until final review publication. The inclusion criteria will be (1) study participants with diabetes; (2) age ≥18 years; (3) creatinine-based CKD-EPI eGFR as index test; (4) measured GFR using the clearance/plasma disappearance of inulin, iohexol, iothalamate, diethylenetriamine-pentaacetic acid (DTPA) or chromium labelled ethylenediaminetetraacetic acid (Cr-EDTA) as reference test; (5) report of the diagnostic accuracy of the index test. Exclusion criteria will be participants with renal transplant, chronic use of corticosteroids, chronic inflammatory diseases, pregnancy, non-diabetes related kidney disease, thalassaemia, heart failure, pregnancy and potential kidney donors as well as critically ill patients. Screening, eligibility check, risk of bias assessment and data extraction will be carried out by two independent reviewers. Any discrepancies will be discussed, and third-party opinion will be sought. The risk of bias will be assessed using the Quality Assessment of Diagnostic Accuracy Studies−2 tool. A quantitative synthesis of the aggregated-data will be used if the included studies are homogenous.Ethics and disseminationNo ethics approval is required. The outcome will be published in a peer-reviewed journal. The results will help researchers and clinicians evaluate the diagnostic accuracy of the creatinine-based CKD-EPI eGFR in adults with diabetes.PROSPERO registration numberCRD42018108776

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The Diagnostic Accuracy of Bleeding Assessment Tools for the Identification of Patients with Mild Bleeding Disorders: A Systematic Review

Blood ◽

10.1182/blood.v126.23.4473.4473 ◽

2015 ◽

Vol 126 (23) ◽

pp. 4473-4473

Author(s):

Floor CJI Moenen ◽

Yvonne MC Henskens ◽

Saskia AM Schols ◽

Patty J Nelemans ◽

Harry C. Schouten ◽

...

Keyword(s):

High Risk ◽

Diagnostic Accuracy ◽

Patient Selection ◽

Validation Studies ◽

Bleeding Disorder ◽

Risk Of Bias ◽

Index Test ◽

Bleeding Disorders ◽

Reference Standard ◽

Mild Bleeding Disorders

Abstract Introduction A study of diagnostic test accuracy compares a single index test to a gold standard to determine status of disease. The observed accuracy of a test varies among patient subgroups and is sensitive to bias. To achieve reliable estimates of diagnostic accuracy, an appropriate study design in a clinically relevant population is warranted. Recently a review was published about the evolution of the bleeding assessment tool (BAT) in diagnosing patients with mild bleeding disorders (MBD) (Rydz et al. J Thromb Haemost 2012). Many validation studies have been done. However, a critical appraisal addressing the quality of these validation studies is lacking. Objective We performed a systematic review to determine the quality and applicability of studies assessing the diagnostic utility of the BAT for MBD among clinic based cohorts. Methods The literature search was conducted using the electronic database PubMed. The final search date was March 2, 2015. The search terms: 'bleeding disorder OR bleeding tendency' AND 'bleeding questionnaire' were used. All studies assessing the diagnostic accuracy of bleeding questionnaires in identifying adults (age > 18 years) with MBD were considered eligible, irrespective of study design or used reference standard. The methodological quality and applicability of each included study was assessed using a Quality Assessment of Diagnostic studies-2 (QUADAS-2) tool. This tool consists of four domains specific for patient selection, index test, reference standard and participant flow. For each domain bias was assessed using signaling questions, for the first three domains applicability was assessed. Results The search yielded 530 citations, from which 35 possible relevant full-text studies were identified. Twenty-two studies were excluded, reasons for exclusion were: letter to the editor, validation of questionnaire combined with laboratory results and primary care population. Table 1 shows the 13 included studies, the assessed BAT and the targeted bleeding condition. Risk of bias and applicability concerns are summarized in figure 1. In 77% of the studies there was a high risk of bias for patient selection and applicability concerns. Many studies used a case control design, comparing patients with a known bleeding disorder with healthy controls. This leads to spectrum bias and might generate higher estimates of sensitivity and specificity (Rutjes et al. Clin Chem 2005). In 46% there was a high risk of bias for index test due to the use of a self-administered questionnaire or because the person conducting the questionnaire was aware of the diagnosis. This leads to observer bias caused by better awareness and over-reporting of bleeding symptoms. Finally, there was high risk of bias in study flow in 38% of the studies. These studies included symptoms after diagnosis of the bleeding disorder. Since bleeding disorders are managed by interventions to prevent bleeding, underestimation of the bleeding symptoms may occur. Conclusion This review highlights the difficulties and advantages of the BAT validation studies. It provides the ability for medical practitioners to apply the BAT with full awareness of its restrictions and benefits. With the evaluation of the risks of bias in the included studies we highlighted limitations, especially in method of patient selection and use of index test, that future studies preferably should try to avoid. Disclosures No relevant conflicts of interest to declare.

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Optimising the Cutoffs of Cognitive Screening Instruments in Pragmatic Diagnostic Accuracy Studies: Maximising Accuracy or the Youden Index?

Dementia and Geriatric Cognitive Disorders ◽

10.1159/000369883 ◽

2015 ◽

Vol 39 (3-4) ◽

pp. 167-175 ◽

Cited By ~ 25

Author(s):

Andrew J. Larner

Keyword(s):

Diagnostic Accuracy ◽

Alternative Methods ◽

Youden Index ◽

Test Accuracy ◽

Screening Instruments ◽

Cognitive Screening ◽

Optimal Method ◽

Index Method ◽

State Examination ◽

Addenbrooke’S Cognitive Examination

Background/Aims: The optimal method of establishing test cutoffs or cutpoints for cognitive screening instruments (CSIs) is uncertain. Of the available methods, two base cutoffs on either the maximal test accuracy or the maximal Youden index. The aim of this study was to compare the effects of using these alternative methods of establishing cutoffs. Methods: Datasets from three pragmatic diagnostic accuracy studies which examined the Mini-Mental State Examination (MMSE), the Addenbrooke's Cognitive Examination-Revised (ACE-R), the Montreal Cognitive Assessment (MoCA), and the Test Your Memory (TYM) test were analysed to calculate test sensitivity and specificity using cutoffs based on either maximal test accuracy or the maximal Youden index. Results: For ACE-R, MoCA, and TYM, optimal cutoffs for dementia diagnosis differed from those in index studies when defined using either the maximal accuracy or the maximal Youden index method. Optimal cutoffs were higher for MMSE, MoCA, and TYM when using the maximal Youden index method and consequently more sensitive. Conclusion: Revision of the cutoffs for CSIs established in index studies may be required to optimise performance in pragmatic diagnostic test accuracy studies which more closely resemble clinical practice.

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