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European Radiology Oct 2023To perform a systematic review comparing the diagnostic accuracy of MRI vs. CT for assessing pancreatic ductal adenocarcinoma (PDAC) vascular invasion. (Meta-Analysis)
Meta-Analysis
OBJECTIVES
To perform a systematic review comparing the diagnostic accuracy of MRI vs. CT for assessing pancreatic ductal adenocarcinoma (PDAC) vascular invasion.
METHODS
MEDLINE, EMBASE, Cochrane Central, and Scopus were searched until December 2021 for diagnostic accuracy studies comparing MRI vs. CT to evaluate vascular invasion of pathologically confirmed PDAC in the same patients. Findings on resection or exploratory laparotomy were the preferred reference standard. Data extraction, risk of bias, and applicability assessment were performed by two authors using the Quality Assessment of Diagnostic Accuracy Studies-Comparative Tool. Bivariate random-effects meta-analysis and meta-regression were performed with 95% confidence intervals (95% CI).
RESULTS
Three studies were included assessing 474 vessels without vascular invasion and 65 with vascular invasion in 107 patients. All patients were imaged using MRI at ≥ 1.5 T and a pancreatic protocol CT. No difference was shown between MRI and CT for diagnosing PDAC vascular invasion: MRI/CT sensitivity (95% CI) were 71% (47-87%)/74% (56-86%), and specificity were 97% (94-99%)/97% (94-98%). Sources of bias included selection bias from only a subset of CT patients undergoing MRI and verification bias from patients with unresectable disease not confirmed on surgery. No patients received neoadjuvant therapy prior to staging.
CONCLUSIONS
Based on limited data, no difference was observed between MRI and pancreatic protocol CT for PDAC vascular invasion assessment. MRI may be an adequate substitute for pancreatic protocol CT in some patients, particularly those who have already had a single-phase CT. Larger and more recent cohort studies at low risk of bias, including patients who have received neoadjuvant therapy, are needed.
CLINICAL RELEVANCE STATEMENT
Abdominal MRI performed similarly to pancreatic protocol CT at assessing pancreatic ductal adenocarcinoma vascular invasion, suggesting local staging is adequate in some patients using MRI. More data are needed using larger, more recent cohorts including patients with neoadjuvant treatment.
KEY POINTS
• Based on limited data, no difference was found between MRI and pancreatic protocol CT sensitivity and specificity for diagnosing PDAC vascular invasion (p = 0.81, 0.73 respectively). • Risk of bias could be reduced in future PDAC MRI vs CT comparative diagnostic test accuracy research by ensuring all enrolled patients undergo both imaging modalities being compared in random order and regardless of the findings on either modality. • More studies are needed that directly compare the diagnostic performance of MRI and CT for PDAC staging after neoadjuvant therapy.
Topics: Humans; Pancreatic Neoplasms; Adenocarcinoma; Tomography, X-Ray Computed; Magnetic Resonance Imaging; Carcinoma, Pancreatic Ductal; Sensitivity and Specificity; Diagnostic Tests, Routine
PubMed: 37083741
DOI: 10.1007/s00330-023-09659-0 -
Journal of Advanced Nursing Oct 2020To evaluate the diagnostic test accuracy of the Nursing Delirium Screening Scale through a systematic review and meta-analysis. (Meta-Analysis)
Meta-Analysis Review
AIMS
To evaluate the diagnostic test accuracy of the Nursing Delirium Screening Scale through a systematic review and meta-analysis.
DESIGN
A systematic review with meta-analysis.
DATA SOURCES
Articles were searched systematically in the MEDLINE, EMBASE, PsycINFO, and CINAHL databases up to April 2019.
REVIEW METHODS
Data extraction and quality assessment were conducted using the Quality Assessment of the Diagnostic Accuracy Studies-2 tool. Pooled sensitivities, specificities, likelihood ratio, and diagnostic odds ratio for the tool were estimated and its hierarchical summary receiver-operating characteristic curve was derived through a bivariate model meta-analysis.
RESULTS
Eleven studies with a total of 2,245 patients were included in this review. The pooled estimates of sensitivity and specificity of the Nursing Delirium Screening Scale were 68.6% (95% confidence interval; 55.3%, 79.5%) and 89.4% (83.3%, 93.5%), respectively. The pooled estimate of the area under the hierarchical summary receiver-operating characteristic curve was 0.88.
CONCLUSION
Use of the Nursing Delirium Screening Scale provides moderate to high sensitivity and high specificity. This review supports the Nursing Delirium Screening Scale as a validate tool of screening for delirium.
IMPACT
With the best evidence of the accuracy of the Nursing Delirium Screening Scale, we recommend nursing leaders to use this easy-to-use and validated tool for daily screening of delirium in any hospital setting, which possibly contribute to an early detection of delirium and, ultimately, assist to obtain an accurate estimation of prevalence of delirium.
Topics: Delirium; Diagnostic Tests, Routine; Humans; Mass Screening; ROC Curve; Sensitivity and Specificity
PubMed: 32869373
DOI: 10.1111/jan.14482 -
The Lancet. Microbe Apr 2024Accurate diagnosis is pivotal for implementing strategies for surveillance, control, and elimination of schistosomiasis. Despite their low sensitivity in low-endemicity... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Accurate diagnosis is pivotal for implementing strategies for surveillance, control, and elimination of schistosomiasis. Despite their low sensitivity in low-endemicity areas, microscopy-based urine filtration and the Kato-Katz technique are considered as reference diagnostic tests for Schistosoma haematobium and Schistosoma mansoni infections, respectively. We aimed to collate all available evidence on the accuracy of other proposed diagnostic techniques.
METHODS
In this systematic review and meta-analysis, we searched PubMed, Embase, the Cochrane Library, and LILACS for studies published from database inception to Dec 31, 2022, investigating the sensitivity and specificity of diagnostic tests for S haematobium and S mansoni infections against Kato-Katz thick smears or urine microscopy (reference tests) involving adults (aged ≥18 years), school-aged children (aged 7 to 18 years), or preschool-aged children (aged 1 month to 7 years). We extracted raw data on true positives, true negatives, false positives, and false negatives for the diagnostic tests and data on the number of participants, study authors, publication year, journal, study design, participants' age and sex, prevalence of Schistosoma infection, and treatment status. To account for imperfect reference tests, we used a hierarchical Bayesian latent class meta-analysis to model test accuracy.
FINDINGS
Overall, we included 121 studies, assessing 28 different diagnostic techniques. Most studies (103 [85%] of 121) were done in Africa, 14 (12%) in South America, one (1%) in Asia, and one (1%) in an unknown country. Compared with the reference test, Kato-Katz thick smears, circulating cathodic antigen urine cassette assay version 1 (CCA1, 36 test comparisons) had excellent sensitivity (95% [95% credible interval 88-99]) and reasonable specificity (74% [63-83]) for S mansoni. ELISA-based tests had a performance comparable to circulating cathodic antigen, but there were few available test comparisons. For S haematobium, proteinuria (42 test comparisons, sensitivity 73% [62-82]; specificity 94% [89-98]) and haematuria (75 test comparisons, sensitivity 85% [80-90]; specificity 96% [92-99]) reagent strips showed high specificity, with haematuria reagent strips having better sensitivity. Despite limited data, nucleic acid amplification tests (NAATs; eg, PCR or loop-mediated isothermal amplification [LAMP]) showed promising results with sensitivity estimates above 90%. We found an unclear risk of bias of about 70% in the use of the reference or index tests and of 50% in patient selection. All analyses showed substantial heterogeneity (I>80%).
INTERPRETATION
Although NAATs and immunological diagnostics show promise, the limited information available precludes drawing definitive conclusions. Additional research on diagnostic accuracy and cost-effectiveness is needed before the replacement of conventional tests can be considered.
FUNDING
WHO and Luxembourg Institute of Health.
Topics: Child; Child, Preschool; Adult; Animals; Humans; Adolescent; Schistosoma mansoni; Schistosoma haematobium; Hematuria; Reagent Strips; Microscopy; Bayes Theorem; Feces; Antigens, Helminth; Urinalysis; Schistosomiasis haematobia; Diagnostic Tests, Routine
PubMed: 38467130
DOI: 10.1016/S2666-5247(23)00377-4 -
Biomedical Engineering Online Dec 2023This systematic review and meta-analysis were conducted to objectively evaluate the evidence of machine learning (ML) in the patient diagnosis of Intracranial Hemorrhage... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
This systematic review and meta-analysis were conducted to objectively evaluate the evidence of machine learning (ML) in the patient diagnosis of Intracranial Hemorrhage (ICH) on computed tomography (CT) scans.
METHODS
Until May 2023, systematic searches were conducted in ISI Web of Science, PubMed, Scopus, Cochrane Library, IEEE Xplore Digital Library, CINAHL, Science Direct, PROSPERO, and EMBASE for studies that evaluated the diagnostic precision of ML model-assisted ICH detection. Patients with and without ICH as the target condition who were receiving CT-Scan were eligible for the research, which used ML algorithms based on radiologists' reports as the gold reference standard. For meta-analysis, pooled sensitivities, specificities, and a summary receiver operating characteristics curve (SROC) were used.
RESULTS
At last, after screening the title, abstract, and full paper, twenty-six retrospective and three prospective, and two retrospective/prospective studies were included. The overall (Diagnostic Test Accuracy) DTA of retrospective studies with a pooled sensitivity was 0.917 (95% CI 0.88-0.943, I = 99%). The pooled specificity was 0.945 (95% CI 0.918-0.964, I = 100%). The pooled diagnostic odds ratio (DOR) was 219.47 (95% CI 104.78-459.66, I = 100%). These results were significant for the specificity of the different network architecture models (p-value = 0.0289). However, the results for sensitivity (p-value = 0.6417) and DOR (p-value = 0.2187) were not significant. The ResNet algorithm has higher pooled specificity than other algorithms with 0.935 (95% CI 0.854-0.973, I = 93%).
CONCLUSION
This meta-analysis on DTA of ML algorithms for detecting ICH by assessing non-contrast CT-Scans shows the ML has an acceptable performance in diagnosing ICH. Using ResNet in ICH detection remains promising prediction was improved via training in an Architecture Learning Network (ALN).
Topics: Humans; Prospective Studies; Sensitivity and Specificity; Retrospective Studies; Algorithms; Machine Learning; Diagnostic Tests, Routine
PubMed: 38049809
DOI: 10.1186/s12938-023-01172-1 -
Pediatric Nephrology (Berlin, Germany) Oct 2023Severity of acute kidney injury (AKI) confers higher odds of mortality. Timely recognition and early initiation of preventive measures may help mitigate the injury... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Severity of acute kidney injury (AKI) confers higher odds of mortality. Timely recognition and early initiation of preventive measures may help mitigate the injury further. Novel biomarkers may aid in the early detection of AKI. The utility of these biomarkers across various clinical settings in children has not been evaluated systematically.
OBJECTIVE
To synthesize the currently available evidence on different novel biomarkers for the early diagnosis of AKI in pediatric patients.
DATA SOURCES
We searched four electronic databases (PubMed, Web of Science, Embase, and Cochrane Library) for studies published between 2004 and May 2022.
STUDY ELIGIBILITY CRITERIA
Cohort and cross-sectional studies evaluating the diagnostic performance of biomarkers in predicting AKI in children were included.
PARTICIPANTS AND INTERVENTIONS
Participants in the study included children (aged less than 18 years) at risk of AKI.
STUDY APPRAISAL AND SYNTHESIS METHODS
We used the QUADAS-2 tool for the quality assessment of the included studies. The area under the receiver operating characteristics (AUROC) was meta-analyzed using the random-effect inverse-variance method. Pooled sensitivity and specificity were generated using the hierarchical summary receiver operating characteristic (HSROC) model.
RESULTS
We included 92 studies evaluating 13,097 participants. Urinary NGAL and serum cystatin C were the two most studied biomarkers, with summary AUROC of 0.82 (0.77-0.86) and 0.80 (0.76-0.85), respectively. Among others, urine TIMP-2*IGFBP7, L-FABP, and IL-18 showed fair to good predicting ability for AKI. We observed good diagnostic performance for predicting severe AKI by urine L-FABP, NGAL, and serum cystatin C.
LIMITATIONS
Limitations were significant heterogeneity and lack of well-defined cutoff value for various biomarkers.
CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS
Urine NGAL, L-FABP, TIMP-2*IGFBP7, and cystatin C showed satisfactory diagnostic accuracy in the early prediction of AKI. To further improve the performance of biomarkers, they need to be integrated with other risk stratification models.
SYSTEMATIC REVIEW REGISTRATION
PROSPERO (CRD42021222698). A higher resolution version of the Graphical abstract is available as "Supplementary information".
Topics: Humans; Child; Lipocalin-2; Tissue Inhibitor of Metalloproteinase-2; Cystatin C; Cross-Sectional Studies; Biomarkers; Acute Kidney Injury; Diagnostic Tests, Routine
PubMed: 36862250
DOI: 10.1007/s00467-023-05891-4 -
BMC Infectious Diseases Jul 2019Lassa fever virus has been enlisted as a priority pathogen of epidemic potential by the World Health organization Research and Development (WHO R & D) Blueprint....
BACKGROUND
Lassa fever virus has been enlisted as a priority pathogen of epidemic potential by the World Health organization Research and Development (WHO R & D) Blueprint. Diagnostics play a crucial role in epidemic preparedness. This systematic review was conducted to determine the sensitivity and specificity of Lassa fever diagnostic tests for humans.
METHODS
We searched OVID Medline, OVID Embase, Scopus and Web of Science for laboratory based and field studies that reported the performance of diagnostic tests for Lassa fever in humans from 1 January 1990 to 25 January 2019. Two reviewers independently screened all the studies and included only studies that involved the evaluation of a Lassa fever diagnostic test and provided data on the sensitivity and specificity. The quality of the studies was assessed using the QUADAS-2 criteria. Data on the study location, study design, type of sample, index test, reference tests and diagnostic performance were extracted from the studies.
RESULTS
Out of a total of 1947 records identified, 1245 non-duplicate citations were obtained. Twenty-six (26) full-text articles examined which identified 08 studies meeting pre-defined criteria. Only one study was a field evaluation study. The sensitivity and specificity of the point of care (RDT) against the Nikisins qPCR were 91.2%(95% CI:75.2-97.7) and 86%(95% CI: 71.4-94.2) at temperatures 18-30 °C, while the sensitivity and specificity of the single IgM ELISA assay against standard RT-PCR were 31.1%(95%CI: 25.6-37) and 95.7%(95%CI:92.8-97.7). The sensitivity of the combined ELISA Antigen/IgM assay(against virus isolation), the recombinant IgM/IgG ELISA(against standard RT-PCR), and the IgM/IgG immunoblot(against IFA) were 88%(95%CI:77-95), 25.9%(95%CI:20.8-31.6), and 90.7%(95%CI:84.13-97.27) respectively. The specificity of the combined ELISA Antigen/IgM assay(against virus isolation), the recombinant IgM/IgG ELISA(against standard RT-PCR), and the IgM/IgG immunoblot(against IFA) were 90%(95%CI:88-91), 100%(95%CI:98.2-100), and 96.3%(95%CI:92.2-100) respectively.
CONCLUSION
Lassa fever has assays for antigenaemia, IgM, IgG and PCR detection. The RDT reportedly performed well but more data are needed from other countries and at temperatures above 30 °C. Most combined immunoassays perform better than the single IgM. Multiplex and pan-Lassa assays are needed. More well conducted field studies are needed.
TRIAL REGISTRATION
Prospero registration number: CRD42018091585 .
Topics: Diagnostic Tests, Routine; Enzyme-Linked Immunosorbent Assay; Humans; Immunoblotting; Lassa Fever; Lassa virus; Point-of-Care Systems; Polymerase Chain Reaction; Sensitivity and Specificity
PubMed: 31324229
DOI: 10.1186/s12879-019-4242-6 -
Journal of Obstetrics and Gynaecology :... Dec 2024The diagnosis of endometriomas in patients with endometriosis is of primary importance because it influences the management and prognosis of infertility and pain.... (Meta-Analysis)
Meta-Analysis Review
INTRODUCTION
The diagnosis of endometriomas in patients with endometriosis is of primary importance because it influences the management and prognosis of infertility and pain. Imaging techniques are evolving constantly. This study aimed to systematically assess the diagnostic accuracy of transvaginal ultrasound (TVUS) and magnetic resonance imaging (MRI) in detecting endometrioma using the surgical visualisation of lesions with or without histopathological confirmation as reference standards in patients of reproductive age with suspected endometriosis.
METHODS
PubMed, Embase, Web of Science, Cumulative Index to Nursing and Allied Health Literature and ClinicalTrials.gov databases were searched from their inception to 12 October 2022, using a manual search for additional articles. Two authors independently performed title, abstract and full-text screening of the identified records, extracted study details and quantitative data and assessed the quality of the studies using the 'Quality Assessment of Diagnostic Accuracy Study 2' tool. Bivariate random-effects models were used to determine the pooled sensitivity and specificity, compare the two imaging modalities and evaluate the sources of heterogeneity.
RESULTS
Sixteen prospective studies (10 assessing TVUS, 4 assessing MRI and 2 assessing both TVUS and MRI) were included, representing 1976 participants. Pooled TVUS and MRI sensitivities for endometrioma were 0.89 (95% confidence interval 'CI', 0.86-0.92) and 0.94 (95% CI, 0.74-0.99), respectively (indirect comparison -value of 0.47). Pooled TVUS and MRI specificities for endometrioma were 0.95 (95% CI, 0.92-0.97) and 0.94 (95% CI, 0.89-0.97), respectively (indirect comparison p-value of 0.51). These studies had a high or unclear risk of bias. A direct comparison (all participants undergoing TVUS and MRI) of the modalities was available in only two studies.
CONCLUSION
TVUS and MRI have high accuracy for diagnosing endometriomas; however, high-quality studies comparing the two modalities are lacking.
Topics: Female; Humans; Endometriosis; Prospective Studies; Ultrasonography; Magnetic Resonance Imaging; Sensitivity and Specificity; Diagnostic Tests, Routine
PubMed: 38348799
DOI: 10.1080/01443615.2024.2311664 -
International Journal of Fertility &... Apr 2021The aim of this study is to review current indications to diagnostic and/or operative hysteroscopy in primary and secondary infertility, as well as to determine its... (Review)
Review
BACKGROUND
The aim of this study is to review current indications to diagnostic and/or operative hysteroscopy in primary and secondary infertility, as well as to determine its efficacy in improving fertility.
MATERIALS AND METHODS
We gathered available evidence about the role of hysteroscopy in the management of various infertility conditions. Literature from 2000 to 2020 that pertained to this topic were retrieved and appropriately selected.
RESULTS
Hysteroscopy does not appear as a first line diagnostic procedure for every clinical scenario. However, its diagnostic sensitivity and specificity in assessing intrauterine pathology is superior to all other non-invasive techniques, such as saline infusion/gel instillation sonography (SIS/GIS), transvaginal sonography (TVS) and hysterosalpingography (HSG). Hysteroscopy allows not only a satisfactory evaluation of the uterine cavity but also, the eventual treatment of endocavitary pathologies that may affect fertility both in spontaneous and assisted reproductive technology (ART) cycles.
CONCLUSION
Hysteroscopy, due to its diagnostic and therapeutic potential, should be regarded as a necessary step in infertility management. However, in case of suspected uterine malformation, hysteroscopy should be integrated with other tests [three-dimensional (3D) ultrasound or magnetic resonance imaging (MRI)] for diagnostic confirmation.
PubMed: 33687159
DOI: 10.22074/IJFS.2020.134704 -
Journal of Minimally Invasive Gynecology Apr 2021To assess the diagnostic accuracy of hysteroscopy compared with that of laparoscopic chromopertubation for the detection of fallopian tubal obstruction. (Meta-Analysis)
Meta-Analysis Review
OBJECTIVE
To assess the diagnostic accuracy of hysteroscopy compared with that of laparoscopic chromopertubation for the detection of fallopian tubal obstruction.
DATA SOURCES
An electronic search from inception to March 31, 2020, was performed in Medline, Scopus, EMBASE, and the Cochrane Central Register of Controlled Trials.
METHODS OF STUDY SELECTION
This diagnostic accuracy meta-analysis was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses and Synthesizing Evidence from Diagnostic Accuracy Tests recommendations. A combination of the following Medical Subject Headings terms and keywords was included in the search strategy: "hysteroscopy[MeSH]," "tubal obstruction," "tubal patency," "tubal dysfunction," and "tubal blockage." Quality assessment of the included studies was conducted using the Quality Assessment Tool for Diagnostic Accuracy Studies-2 (University of Bristol, Bristol, United Kingdom). Publication bias was evaluated by means of the Deek funnel plot asymmetry test. The following outcomes were analyzed: diagnostic odds ratio, area under hierarchical summary receiver operating characteristic and area under receiver operating characteristic curve, sensitivity, specificity, and positive and negative likelihood ratios.
TABULATION, INTEGRATION, AND RESULTS
Six studies comparing hysteroscopy with laparoscopic chromopertubation were included in the meta-analysis. After pooling all the studies, the diagnostic odds ratio was 43. The evaluated area under receiver operating characteristic curve was 0.93, correlating with high diagnostic accuracy for the index test. Sensitivity and specificity were 88% and 85%, respectively. In addition, the positive and negative likelihood ratios were 5.88 and 0.16, respectively.
CONCLUSION
Hysteroscopic techniques are highly accurate and sensitive for detecting fallopian tubal obstruction. Interventional assessment enhances diagnostic accuracy compared with observational assessment, as does the office setting compared with the operating room. Additional studies, along with a refinement of the techniques, could facilitate the widespread use of hysteroscopic techniques for the detection of fallopian tube occlusion.
Topics: Diagnostic Tests, Routine; Fallopian Tube Diseases; Fallopian Tubes; Female; Humans; Hysteroscopy; Infertility, Female; Laparoscopy; Pregnancy; Sensitivity and Specificity
PubMed: 33246040
DOI: 10.1016/j.jmig.2020.11.013 -
Health Technology Assessment... Jun 2006To determine the most effective diagnostic strategy for the investigation of microscopic and macroscopic haematuria in adults. (Review)
Review
OBJECTIVES
To determine the most effective diagnostic strategy for the investigation of microscopic and macroscopic haematuria in adults.
DATA SOURCES
Electronic databases from inception to October 2003, updated in August 2004.
REVIEW METHODS
A systematic review was undertaken according to published guidelines. Decision analytic modelling was undertaken, based on the findings of the review, expert opinion and additional information from the literature, to assess the relative cost-effectiveness of plausible alternative tests that are part of diagnostic algorithms for haematuria.
RESULTS
A total of 118 studies met the inclusion criteria. No studies that evaluated the effectiveness of diagnostic algorithms for haematuria or the effectiveness of screening for haematuria or investigating its underlying cause were identified. Eighteen out of 19 identified studies evaluated dipstick tests and data from these suggested that these are moderately useful in establishing the presence of, but cannot be used to rule out, haematuria. Six studies using haematuria as a test for the presence of a disease indicated that the detection of microhaematuria cannot alone be considered a useful test either to rule in or rule out the presence of a significant underlying pathology (urinary calculi or bladder cancer). Forty-eight of 80 studies addressed methods to localise the source of bleeding (renal or lower urinary tract). The methods and thresholds described in these studies varied greatly, precluding any estimate of a 'best performance' threshold that could be applied across patient groups. However, studies of red blood cell morphology that used a cut-off value of 80% dysmorphic cells for glomerular disease reported consistently high specificities (potentially useful in ruling in a renal cause for haematuria). The reported sensitivities were generally low. Twenty-eight studies included data on the accuracy of laboratory tests (tumour markers, cytology) for the diagnosis of bladder cancer. The majority of tumour marker studies evaluated nuclear matrix protein 22 or bladder tumour antigen. The sensitivity and specificity ranges suggested that neither of these would be useful either for diagnosing bladder cancer or for ruling out patients for further investigation (cystoscopy). However, the evidence remains sparse and the diagnostic accuracy estimates varied widely between studies. Fifteen studies evaluating urine cytology as a test for urinary tract malignancies were heterogeneous and poorly reported. The calculated specificity values were generally high, suggesting some possible utility in confirming malignancy. However, the evidence suggests that urine cytology has no application in ruling out malignancy or excluding patients from further investigation. Fifteen studies evaluated imaging techniques [computed tomography (CT), intravenous urography (IVU) or ultrasound scanning (US)] to detect the underlying cause of haematuria. The target condition and the reference standard varied greatly between these studies. The diagnostic accuracy data for several individual studies appeared promising but meaningful comparison of the available imaging technologies was impossible. Eight studies met the inclusion criteria but addressed different parts of the diagnostic chain (e.g. screening programmes, laboratory investigations, full urological work-up). No single study addressed the complete diagnostic process. The review also highlighted a number of methodological limitations of these studies, including their lack of generalisability to the UK context. Separate decision analytic models were therefore developed to progress estimation of the optimal strategy for the diagnostic management of haematuria. The economic model for the detection of microhaematuria found that immediate microscopy following a positive dipstick test would improve diagnostic efficiency as it eliminates the high number of false positives produced by dipstick testing. Strategies that use routine microscopy may be associated with high numbers of false results, but evidence was lacking regarding the accuracy of routine microscopy and estimates were adopted for the model. The model for imaging the upper urinary tract showed that US detects more tumours than IVU at one-third of the cost, and is also associated with fewer false results. For any cause of haematuria, CT was shown to have a mean incremental cost-effectiveness ratio of pounds sterling 9939 in comparison with the next best option, US. When US is followed up with CT for negative results with persistent haematuria, it dominates the initial use of CT alone, with a saving of pounds sterling 235,000 for the evaluation of 1000 patients. The model for investigation of the lower urinary tract showed that for low-risk patients the use of immediate cystoscopy could be avoided if cystoscopy were used for follow-up patients with a negative initial test using tumour markers and/or cytology, resulting in a saving of pounds sterling 483,000 for the evaluation of 1000 patients. The clinical and economic impact on delayed detection of both upper and lower urinary tract tumours through the use of follow-up testing should be evaluated in future studies.
CONCLUSIONS
There are insufficient data currently available to derive an evidence-based algorithm of the diagnostic pathway for haematuria. A hypothetical algorithm based on the opinion and practice of clinical experts in the review team, other published algorithms and the results of economic modelling is presented in this report. This algorithm is presented, for comparative purposes, alongside current US and UK guidelines. The ideas contained in these algorithms and the specific questions outlined should form the basis of future research. Quality assessment of the diagnostic accuracy studies included in this review highlighted several areas of deficiency.
Topics: Algorithms; Cost-Benefit Analysis; Diagnostic Tests, Routine; Hematuria; Humans; State Medicine; United Kingdom
PubMed: 16729917
DOI: 10.3310/hta10180