13a. Information available to performers or readers of the index test

What to write

Whether clinical information and reference standard results were available to the performers or readers of the index test.

Example

‘Images for each patient were reviewed by two fellowship-trained genitourinary radiologists with 12 and 8 years of experience, respectively, who were blinded to all patient information, including the final histopathologic diagnosis’.1

Explanation

(NB the explanation and example for items 13a and 13b are the same.)

Some medical tests, such as most forms of imaging, require human handling, interpretation and judgement. These actions may be influenced by the information that is available to the reader.23,4 This can lead to artificially high agreement between tests, or between the index test and the reference standard.

If the reader of a test has access to information about signs, symptoms and previous test results, the reading may be influenced by this additional information, but this may still represent how the test is used in clinical practice.5 The reverse may also apply, if the reader does not have enough information for a proper interpretation of the index test outcome. In that case, test performance may be affected downwards, and the study findings may have limited applicability. Either way, readers of the study report should know to which extent, such additional information was available to test readers and may have influenced their final judgement.

In other situations, the assessors of the reference standard may have had access to the index test results. In those cases, the final classification may be guided by the index test result, and the reported accuracy estimates for the index test will be too high.2,56 Tests that require subjective interpretation are particularly susceptible to this bias.

Withholding information from the readers of the test is commonly referred to as ‘blinding’ or ‘masking’. The point of this reporting item is not that blinding is desirable or undesirable, but, rather, that readers of the study report need information about blinding for the index test and the reference standard to be able to interpret the study findings.

In the example, the readers of unenhanced CT for differentiating between renal angiomyolipoma and renal cell carcinoma did not have access to clinical information, nor to the results of histopathology, the reference standard in this study.

Training

The UK EQUATOR Centre runs training on how to write using reporting guidelines.

Discuss this item

Visit this items’ discussion page to ask questions and give feedback.

References

1.
Hodgdon T, McInnes MDF, Schieda N, Flood TA, Lamb L, Thornhill RE. Can quantitative CT texture analysis be used to differentiate fat-poor renal angiomyolipoma from renal cell carcinoma on unenhanced CT images? Radiology. 2015;276(3):787-796. doi:10.1148/radiol.2015142215
2.
Whiting P, Rutjes AWS, Reitsma JB, Glas AS, Bossuyt PMM, Kleijnen J. Sources of variation and bias in studies of diagnostic accuracy: A systematic review. Annals of Internal Medicine. 2004;140(3):189-202. doi:10.7326/0003-4819-140-3-200402030-00010
3.
Begg CB. Biases in the assessment of diagnostic tests. Statistics in Medicine. 1987;6(4):411-423. doi:10.1002/sim.4780060402
4.
Doubilet P, Herman P. Interpretation of radiographs: Effect of clinical history. American Journal of Roentgenology. 1981;137(5):1055-1058. doi:10.2214/ajr.137.5.1055
5.
Whiting PF, Rutjes AWS, Westwood ME, Mallett S. A systematic review classifies sources of bias and variation in diagnostic test accuracy studies. Journal of Clinical Epidemiology. 2013;66(10):1093-1104. doi:10.1016/j.jclinepi.2013.05.014
6.
Philbrick JT, Horwitz RI, Feinstein AR. Methodologic problems of exercise testing for coronary artery disease: Groups, analysis and bias. The American Journal of Cardiology. 1980;46(5):807-812. doi:10.1016/0002-9149(80)90432-4

Citation

For attribution, please cite this work as:
Bossuyt PM, Reitsma JB, Bruns DE, et al. The STARD reporting guideline for writing diagnostic accuracy study articles. The EQUATOR Network guideline dissemination platform. doi:10.1234/equator/1010101

Reporting Guidelines are recommendations to help describe your work clearly

Your research will be used by people from different disciplines and backgrounds for decades to come. Reporting guidelines list the information you should describe so that everyone can understand, replicate, and synthesise your work.

Reporting guidelines do not prescribe how research should be designed or conducted. Rather, they help authors transparently describe what they did, why they did it, and what they found.

Reporting guidelines make writing research easier, and transparent research leads to better patient outcomes.

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Maximum impact

From nobel prizes to null results, articles have more impact when everyone can use them.

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Who reads research?

You work will be read by different people, for different reasons, around the world, and for decades to come. Reporting guidelines help you consider all of your potential audiences. For example, your research may be read by researchers from different fields, by clinicians, patients, evidence synthesisers, peer reviewers, or editors. Your readers will need information to understand, to replicate, apply, appraise, synthesise, and use your work.

Cohort studies

A cohort study is an observational study in which a group of people with a particular exposure (e.g. a putative risk factor or protective factor) and a group of people without this exposure are followed over time. The outcomes of the people in the exposed group are compared to the outcomes of the people in the unexposed group to see if the exposure is associated with particular outcomes (e.g. getting cancer or length of life).

Source.

Case-control studies

A case-control study is a research method used in healthcare to investigate potential risk factors for a specific disease. It involves comparing individuals who have been diagnosed with the disease (cases) to those who have not (controls). By analysing the differences between the two groups, researchers can identify factors that may contribute to the development of the disease.

An example would be when researchers conducted a case-control study examining whether exposure to diesel exhaust particles increases the risk of respiratory disease in underground miners. Cases included miners diagnosed with respiratory disease, while controls were miners without respiratory disease. Participants' past occupational exposures to diesel exhaust particles were evaluated to compare exposure rates between cases and controls.

Source.

Cross-sectional studies

A cross-sectional study (also sometimes called a "cross-sectional survey") serves as an observational tool, where researchers capture data from a cohort of participants at a singular point. This approach provides a 'snapshot'— a brief glimpse into the characteristics or outcomes prevalent within a designated population at that precise point in time. The primary aim here is not to track changes or developments over an extended period but to assess and quantify the current situation regarding specific variables or conditions. Such a methodology is instrumental in identifying patterns or correlations among various factors within the population, providing a basis for further, more detailed investigation.

Source

Systematic reviews

A systematic review is a comprehensive approach designed to identify, evaluate, and synthesise all available evidence relevant to a specific research question. In essence, it collects all possible studies related to a given topic and design, and reviews and analyses their results.

The process involves a highly sensitive search strategy to ensure that as much pertinent information as possible is gathered. Once collected, this evidence is often critically appraised to assess its quality and relevance, ensuring that conclusions drawn are based on robust data. Systematic reviews often involve defining inclusion and exclusion criteria, which help to focus the analysis on the most relevant studies, ultimately synthesising the findings into a coherent narrative or statistical synthesis. Some systematic reviews will include a meta-analysis.

Source

Systematic review protocols

TODO

Meta analyses of Observational Studies

TODO

Randomised Trials

A randomised controlled trial (RCT) is a trial in which participants are randomly assigned to one of two or more groups: the experimental group or groups receive the intervention or interventions being tested; the comparison group (control group) receive usual care or no treatment or a placebo. The groups are then followed up to see if there are any differences between the results. This helps in assessing the effectiveness of the intervention.

Source

Randomised Trial Protocols

TODO

Qualitative research

Research that aims to gather and analyse non-numerical (descriptive) data in order to gain an understanding of individuals' social reality, including understanding their attitudes, beliefs, and motivation. This type of research typically involves in-depth interviews, focus groups, or field observations in order to collect data that is rich in detail and context. Qualitative research is often used to explore complex phenomena or to gain insight into people's experiences and perspectives on a particular topic. It is particularly useful when researchers want to understand the meaning that people attach to their experiences or when they want to uncover the underlying reasons for people's behavior. Qualitative methods include ethnography, grounded theory, discourse analysis, and interpretative phenomenological analysis.

Source

Case Reports

TODO

Diagnostic Test Accuracy Studies

Diagnostic accuracy studies focus on estimating the ability of the test(s) to correctly identify subjects with a predefined target condition, or the condition of interest (sensitivity) as well as to clearly identify those without the condition (specificity).

Prediction Models

Prediction model research is used to test the accurarcy of a model or test in estimating an outcome value or risk. Most models estimate the probability of the presence of a particular health condition (diagnostic) or whether a particular outcome will occur in the future (prognostic). Prediction models are used to support clinical decision making, such as whether to refer patients for further testing, monitor disease deterioration or treatment effects, or initiate treatment or lifestyle changes. Examples of well known prediction models include EuroSCORE II for cardiac surgery, the Gail model for breast cancer, the Framingham risk score for cardiovascular disease, IMPACT for traumatic brain injury, and FRAX for osteoporotic and hip fractures.

Source

Animal Research

TODO

Quality Improvement in Healthcare

Quality improvement research is about finding out how to improve and make changes in the most effective way. It is about systematically and rigourously exploring "what works" to improve quality in healthcare and the best ways to measure and disseminate this to ensure positive change. Most quality improvement effectiveness research is conducted in hospital settings, is focused on multiple quality improvement interventions, and uses process measures as outcomes. There is a great deal of variation in the research designs used to examine quality improvement effectiveness.

Source

Economic Evaluations in Healthcare

TODO

Meta Analyses

A meta-analysis is a statistical technique that amalgamates data from multiple studies to yield a single estimate of the effect size. This approach enhances precision and offers a more comprehensive understanding by integrating quantitative findings. Central to a meta-analysis is the evaluation of heterogeneity, which examines variations in study outcomes to ensure that differences in populations, interventions, or methodologies do not skew results. Techniques such as meta-regression or subgroup analysis are frequently employed to explore how various factors might influence the outcomes. This method is particularly effective when aiming to quantify the effect size, odds ratio, or risk ratio, providing a clearer numerical estimate that can significantly inform clinical or policy decisions.

How Meta-analyses and Systematic Reviews Work Together

Systematic reviews and meta-analyses function together, each complementing the other to provide a more robust understanding of research evidence. A systematic review meticulously gathers and evaluates all pertinent studies, establishing a solid foundation of qualitative and quantitative data. Within this framework, if the collected data exhibit sufficient homogeneity, a meta-analysis can be performed. This statistical synthesis allows for the integration of quantitative results from individual studies, producing a unified estimate of effect size. Techniques such as meta-regression or subgroup analysis may further refine these findings, elucidating how different variables impact the overall outcome. By combining these methodologies, researchers can achieve both a comprehensive narrative synthesis and a precise quantitative measure, enhancing the reliability and applicability of their conclusions. This integrated approach ensures that the findings are not only well-rounded but also statistically robust, providing greater confidence in the evidence base.

Why Don't All Systematic Reviews Use a Meta-Analysis?

Systematic reviews do not always have meta-analyses, due to variations in the data. For a meta-analysis to be viable, the data from different studies must be sufficiently similar, or homogeneous, in terms of design, population, and interventions. When the data shows significant heterogeneity, meaning there are considerable differences among the studies, combining them could lead to skewed or misleading conclusions. Furthermore, the quality of the included studies is critical; if the studies are of low methodological quality, merging their results could obscure true effects rather than explain them.

Protocol

A plan or set of steps that defines how something will be done. Before carrying out a research study, for example, the research protocol sets out what question is to be answered and how information will be collected and analysed.

Source

Medical test

Any method for collecting additional information about the current or future health status of a patient.

Index test

The test under evaluation.

Target condition

The disease or condition that the index test is expected to detect.

Clinical reference standard

The best available method for establishing the presence or absence of the target condition; a gold standard would be an error-free reference standard.

Sensitivity

Proportion of those with the target condition who test positive with the index test.

Specificity

Proportion of those without the target condition who test negative with the index test.

Intended use of the test

Whether the index test is used for diagnosis, screening, staging, monitoring, surveillance, prediction, prognosis, or other reasons.

Role of the test

The position of the index test relative to other tests for the same condition (for example, triage, replacement, add-on, new test).

Indeterminate results

Results that are neither positive or negative.