title: The performance of tests of publication bias and other sample size effects in systematic reviews of diagnostic test accuracy was assessed.
abstract: OBJECTIVE
  Publication bias and other sample size effects are issues for meta-analyses of test accuracy, as for randomized trials. We investigate limitations of standard funnel plots and tests when applied to meta-analyses of test accuracy and look for improved methods.
  
  
  METHODS
  Type I and type II error rates for existing and alternative tests of sample size effects were estimated and compared in simulated meta-analyses of test accuracy.
  
  
  RESULTS
  Type I error rates for the Begg, Egger, and Macaskill tests are inflated for typical diagnostic odds ratios (DOR), when disease prevalence differs from 50% and when thresholds favor sensitivity over specificity or vice versa. Regression and correlation tests based on functions of effective sample size are valid, if occasionally conservative, tests for sample size effects. Empirical evidence suggests that they have adequate power to be useful tests. When DORs are heterogeneous, however, all tests of funnel plot asymmetry have low power.
  
  
  CONCLUSIONS
  Existing tests that use standard errors of odds ratios are likely to be seriously misleading if applied to meta-analyses of test accuracy. The effective sample size funnel plot and associated regression test of asymmetry should be used to detect publication bias and other sample size related effects.
authors.affiliation: Screening and Test Evaluation Program, School of Public Health, University of Sydney, Sydney, New South Wales 2006, Australia. Jon.Deeks@cancer.org.uk
authors.forename: Jonathan J
authors.initials: JJ
authors.lastname: Deeks
authors.forename: Petra
authors.initials: P
authors.lastname: Macaskill
authors.forename: Les
authors.initials: L
authors.lastname: Irwig
mesh_terms: D003951:Diagnostic Errors; D006801:Humans; D015201:Meta-Analysis as Topic; D016017:Odds Ratio; D010690:Phlebography; D015995:Prevalence; D017594:Publication Bias; D012372:ROC Curve; D018401:Sample Size; D013223:Statistics as Topic / Q000379:methods; D014463:Ultrasonography; D020246:Venous Thrombosis / Q000000981:diagnostic imaging