Selective cutoff reporting in diagnostic test accuracy studies of depression screening tools: comparing traditional meta-analysis to individual patient data meta-analysis

Tags: Oral
Levis B1, Benedetti A1, Thombs B1
1McGill University, Canada

Background: Selective outcome reporting in clinical trials is well understood, but has not been assessed systematically in studies of diagnostic test accuracy, where authors often report results for a small range of cutoffs around data-driven 'optimal' cutoffs maximizing sensitivity and specificity.

Objectives: To compare traditional meta-analysis of published results to individual patient data (IPD) meta-analysis of results from all cutoffs, to: 1) assess the degree to which selective cutoff reporting exaggerates accuracy estimates; and 2) identify patterns of selective cutoff reporting.

Methods: Bivariate random-effects models were used to compare results of traditional and IPD meta-analysis, using studies included in a published meta-analysis of the Patient Health Questionnaire-9 (PHQ-9) depression-screening tool (Manea, CMAJ, 2012).

Results: Thirteen of 16 primary datasets were obtained. For the 'standard' cutoff of 10, most studies (11 of 13) published accuracy results. For all other cutoffs, only three to six of the 13 studies published accuracy results. For all cutoffs, specificity estimates in traditional and IPD meta-analyses were within 2%. Sensitivity estimates were similar for cutoff 10, but differed by 5% to 15% for all other cutoffs. In samples where the PHQ-9 was poorly sensitive, authors reported results for cutoffs around the low optimal cutoff. In samples where the PHQ-9 was highly sensitive, authors reported results for cutoffs around the high optimal cutoff. Consequently, in the traditional meta-analysis (but not in the IPD meta-analysis), sensitivity increased as cutoff severity increased for part of the range of possible cutoffs. Comparing cutoff 10 across all studies, sensitivity was heterogeneous (tau-squared = 1.95). Comparing optimal cutoffs, however, sensitivity was more homogeneous (tau-squared = 0.68), but cutoff values ranged from 5 to 15.

Conclusion: Selectively reporting well-performing cutoffs in small samples leads to biased estimation of accuracy in traditional meta-analyses. To reduce bias in meta-analyses, primary studies should report accuracy results for all cutoffs.