title: The performance of transient elastography compared to clinical acumen and routine tests - what is the incremental diagnostic value?
abstract: OBJECTIVE
  There is substantial evidence suggesting transient elastography (TE) is a useful tool in assessing liver fibrosis. We aimed to determine whether TE has incremental diagnostic value over clinical acumen and routinely available tests.
  
  
  METHODS
  We performed a retrospective study of 130 patients to assess the ability of hepatologists to predict severity of fibrosis using clinical acumen; clinical acumen with routine tests; and elastography in patients with chronic liver disease. The incremental diagnostic benefit was assessed using the area under the ROC curve (AUC) and the Net Reclassification Index (NRI).
  
  
  RESULTS
  Using universally available tests, including clinical acumen, the AUCs for detection of cirrhosis ranged from 0.70 to 0.80 for the four hepatologists. Elastography led to statistically non-significant improvements in AUC statistics (range 0.83-0.89; P > 0.01). The detection of significant fibrosis using clinical acumen and routine tests was less accurate, with AUCs of 0.52-0.59. Elastography had incremental diagnostic value (AUC performance range 0.76-0.82; P < 0.01). The NRI indicated that 39-58% were correctly reclassified using elastography, especially with respect to sensitivity.
  
  
  CONCLUSIONS
  Our study suggests that the diagnostic value of clinical acumen and routine tests is acceptable for detection of cirrhosis, but not significant fibrosis. Elastography detects significant fibrosis or cirrhosis with acceptable accuracy and offered incremental diagnostic value in detecting significant fibrosis, but not cirrhosis. These findings have implications for determining the diagnostic value of tests over and above routine clinical assessment, which will aid incorporation of novel tests into clinical algorithms.
authors.affiliation: NIHR Biomedical Research Unit (Gastrointestinal and Liver), Nottingham University Hospitals and University of Nottingham, Nottingham, UK.
authors.forename: Grace E
authors.initials: GE
authors.lastname: Dolman
authors.forename: Daan
authors.initials: D
authors.lastname: Nieboer
authors.forename: Ewout W
authors.initials: EW
authors.lastname: Steyerberg
authors.forename: Scott
authors.initials: S
authors.lastname: Harris
authors.forename: Amanda
authors.initials: A
authors.lastname: Ferguson
authors.forename: Abed M
authors.initials: AM
authors.lastname: Zaitoun
authors.forename: Stephen D
authors.initials: SD
authors.lastname: Ryder
authors.forename: Martin W
authors.initials: MW
authors.lastname: James
authors.forename: Guruprasad P
authors.initials: GP
authors.lastname: Aithal
authors.forename: Indra Neil
authors.initials: IN
authors.lastname: Guha
mesh_terms: D019540:Area Under Curve; D002983:Clinical Competence; D003937:Diagnosis, Differential; D003955:Diagnostic Tests, Routine / Q000379:methods*; D054459:Elasticity Imaging Techniques / Q000379:methods*; D006801:Humans; D008103:Liver Cirrhosis / Q000175:diagnosis*; D012189:Retrospective Studies