title: How does study quality affect the results of a diagnostic meta-analysis?
abstract: BACKGROUND
  The use of systematic literature review to inform evidence based practice in diagnostics is rapidly expanding. Although the primary diagnostic literature is extensive, studies are often of low methodological quality or poorly reported. There has been no rigorously evaluated, evidence based tool to assess the methodological quality of diagnostic studies. The primary objective of this study was to determine the extent to which variations in the quality of primary studies impact the results of a diagnostic meta-analysis and whether this differs with diagnostic test type. A secondary objective was to contribute to the evaluation of QUADAS, an evidence-based tool for the assessment of quality in diagnostic accuracy studies.
  
  
  METHODS
  This study was conducted as part of large systematic review of tests used in the diagnosis and further investigation of urinary tract infection (UTI) in children. All studies included in this review were assessed using QUADAS, an evidence-based tool for the assessment of quality in systematic reviews of diagnostic accuracy studies. The impact of individual components of QUADAS on a summary measure of diagnostic accuracy was investigated using regression analysis. The review divided the diagnosis and further investigation of UTI into the following three clinical stages: diagnosis of UTI, localisation of infection, and further investigation of the UTI. Each stage used different types of diagnostic test, which were considered to involve different quality concerns.
  
  
  RESULTS
  Many of the studies included in our review were poorly reported. The proportion of QUADAS items fulfilled was similar for studies in different sections of the review. However, as might be expected, the individual items fulfilled differed between the three clinical stages. Regression analysis found that different items showed a strong association with test performance for the different tests evaluated. These differences were observed both within and between the three clinical stages assessed by the review. The results of regression analyses were also affected by whether or not a weighting (by sample size) was applied. Our analysis was severely limited by the completeness of reporting and the differences between the index tests evaluated and the reference standards used to confirm diagnoses in the primary studies. Few tests were evaluated by sufficient studies to allow meaningful use of meta-analytic pooling and investigation of heterogeneity. This meant that further analysis to investigate heterogeneity could only be undertaken using a subset of studies, and that the findings are open to various interpretations.
  
  
  CONCLUSIONS
  Further work is needed to investigate the influence of methodological quality on the results of diagnostic meta-analyses. Large data sets of well-reported primary studies are needed to address this question. Without significant improvements in the completeness of reporting of primary studies, progress in this area will be limited.
authors.affiliation: Centre for Reviews and Dissemination, University of York, UK. mew3@york.ac.uk
authors.forename: Marie E
authors.initials: ME
authors.lastname: Westwood
authors.forename: Penny F
authors.initials: PF
authors.lastname: Whiting
authors.forename: Jos
authors.initials: J
authors.lastname: Kleijnen
mesh_terms: D002648:Child; D019411:Clinical Laboratory Techniques / Q000592:standards; D003954:Diagnostic Services / Q000592:standards*; D019317:Evidence-Based Medicine; D006801:Humans; D015201:Meta-Analysis as Topic; D015999:Multivariate Analysis; D011787:Quality of Health Care; D012044:Regression Analysis; D012107:Research Design; D018401:Sample Size; D014463:Ultrasonography; D006113:United Kingdom; D014552:Urinary Tract Infections / Q000175:diagnosis* / Q000000981:diagnostic imaging / Q000473:pathology