title: Selection bias introduced by neuropsychological assessments.
abstract: OBJECTIVE
  Two prospective studies in patient with brain tumours were performed comparing the Mini Mental State Examination (MMSE) and the Montreal Cognitive Assessment (MoCA). The first assessed their feasibility and the second compared their diagnostic accuracy against a four-hour neuropsychological assessment (NPA). The introduction of the NPA decreased accrual and retention rates. We were therefore concerned regarding potential selection bias.
  
  
  METHODS
  Ninety-two patients were prospectively accrued and subsequently divided into three categories: a) no NPA required b) withdrew consent to NPA c) completed NPA. In order to quantify any potential bias introduced by the NPA, patient demographics and cognitive test scores were compared between the three groups.
  
  
  RESULTS
  There were significant differences in age (p < 0.001), education (p = 0.034), dexamethasone use (p = 0.002), MMSE (p = 0.005), and MoCA scores (p < 0.001) across the different study groups. Furthermore, with increasing involvement of the NPA, patients' cognitive scores and educational status increased, while their age, dexamethasone use, and opioid use all decreased. Individuals who completed the NPA had higher MoCA scores than individuals who were not asked to complete the NPA (24.7 vs. 20.5; p < 0.001). In addition, this relationship held when restricting the analyses to individuals with brain metastases (p < 0.001).
  
  
  CONCLUSIONS
  In this study, the lengthy NPA chosen introduced a statistically and clinically significant source of selection bias. These results highlight the importance of selecting brief and well tolerated assessments when possible. However, researchers are challenged by weighing the improved selection bias associated with brief assessments at the cost of reduced diagnostic accuracy.
authors.affiliation: BC Cancer Agency, Vancouver Cancer Centre, Vancouver. rolson2@bcancer.bc.ca
authors.forename: Robert
authors.initials: R
authors.lastname: Olson
authors.forename: Maureen
authors.initials: M
authors.lastname: Parkinson
authors.forename: Michael
authors.initials: M
authors.lastname: McKenzie
mesh_terms: D000328:Adult; D000368:Aged; D000704:Analysis of Variance; D001932:Brain Neoplasms / Q000150:complications / Q000175:diagnosis; D003072:Cognition Disorders / Q000175:diagnosis* / Q000453:epidemiology* / Q000209:etiology; D005240:Feasibility Studies; D005260:Female; D006801:Humans; D008297:Male; D008609:Mental Status Schedule; D008875:Middle Aged; D009483:Neuropsychological Tests; D011446:Prospective Studies; D012189:Retrospective Studies; D015983:Selection Bias; D012720:Severity of Illness Index