title: A trivariate meta-analysis of diagnostic studies accounting for prevalence and non-evaluable subjects: re-evaluation of the meta-analysis of coronary CT angiography studies.
abstract: BACKGROUND
  A recent paper proposed an intent-to-diagnose approach to handle non-evaluable index test results and discussed several alternative approaches, with an application to the meta-analysis of coronary CT angiography diagnostic accuracy studies. However, no simulation studies have been conducted to test the performance of the methods.
  
  
  METHODS
  We propose an extended trivariate generalized linear mixed model (TGLMM) to handle non-evaluable index test results. The performance of the intent-to-diagnose approach, the alternative approaches and the extended TGLMM approach is examined by extensive simulation studies. The meta-analysis of coronary CT angiography diagnostic accuracy studies is re-evaluated by the extended TGLMM.
  
  
  RESULTS
  Simulation studies showed that the intent-to-diagnose approach under-estimate sensitivity and specificity. Under the missing at random (MAR) assumption, the TGLMM gives nearly unbiased estimates of test accuracy indices and disease prevalence. After applying the TGLMM approach to re-evaluate the coronary CT angiography meta-analysis, overall median sensitivity is 0.98 (0.967, 0.993), specificity is 0.875 (0.827, 0.923) and disease prevalence is 0.478 (0.379, 0.577).
  
  
  CONCLUSIONS
  Under MAR assumption, the intent-to-diagnose approach under-estimate both sensitivity and specificity, while the extended TGLMM gives nearly unbiased estimates of sensitivity, specificity and prevalence. We recommend the extended TGLMM to handle non-evaluable index test subjects.
authors.affiliation: Division of Biostatistics, School of Public Health, University of Minnesota, A460 Mayo Building, MMC 303, 420 Delaware St, SE, 55455 Minneapolis, MN, USA. xiaoye1043@gmail.com.
authors.forename: Xiaoye
authors.initials: X
authors.lastname: Ma
authors.forename: Muhammad Fareed K
authors.initials: MF
authors.lastname: Suri
authors.forename: Haitao
authors.initials: H
authors.lastname: Chu
mesh_terms: D017023:Coronary Angiography / Q000706:statistics & numerical data*; D003627:Data Interpretation, Statistical; D003935:Diagnostic Techniques, Cardiovascular / Q000706:statistics & numerical data*; D006801:Humans; D015995:Prevalence; D014057:Tomography, X-Ray Computed / Q000706:statistics & numerical data*