Diagnostic accuracy of screening tool for non- specialist health care settings: A summary of findings from ICOPE rapid reviews Jotheeswaran Amuthavalli Thiyagarajan, Matteo Cesari, Suresh Kumar, Carolina Kralj, Finbarr C Martin, Shelly Chadha, John Beard, Islene Araujo de Carvalho WHO Clinical Consortium on Healthy Ageing 21–22 November 2017 BACKGROUND PAPER, 4
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Diagnostic accuracy of screening tool for non- specialist ... · Diagnostic accuracy of screening tool for non-specialist health care settings: A summary of findings from ICOPE rapid
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Cultural bias Yes No Yes No No No Setting Primary care
and community
Primary care and community
Primary care and community
Primary care and community
Primary care and
community
Primary care and community
Sensitivity (%) 80 (95% CI 54-93)
90 (95% CI, 82–95)
93 (95% CI 91-94)
83% (95% CI 69% to 97%)
83% (95%CI 69.2-92.4)
69 %
Specificity (%) 90 (95% CI 74- 96)
87 (95% CI, 72–94).
88 (95% CI 87-89)
80% (95% CI 68-89)
98.4% (95%CI 94.3–99.8)
84%
PPV (95% CI) NA 0.68 0.86 0.65(0.63-0.67)
0.56 0.45
NPV (95% CI) NA 0.98 0.73 0.70(0.67-0.72)
0.97 0.94
Likelihood ratio (+)
2.49 (1.54–4.03)
2.5 NA NA NA 4.45
Likelihood ratio (-)
0.13 (0.08–0.21)
0.05 NA NA NA 0.37
Acceptability for older persons
Yes yes yes yes yes yes
Tested in LAMICs
Yes yes yes yes yes Yes
*LAMIC- Low and Middle Income Countries
First, it is important to underline that all of the identified instruments (GDS, SPPB, MMSE) have
to be considered as screening tools rather than diagnostic tools. Such a characteristic is related
to the fact that 1) physical and mental capacity results from the interaction of multiple
systems and apparatuses beyond the measured domain, and 2) a nosological condition
focused on the impairments is not yet objectively operationalised. For example, the ICD-10-
CM diagnosis code has been released for sarcopenia. However, sarcopenia is a clinical
condition requiring the simultaneous assessment of muscle quantity (i.e. muscle mass) and
quality (i.e. muscle strength). Therefore, no objective instrument can singularly and
independently serve as the diagnostic tool.
None of the studies included in this review considered the potential disadvantages of
screening, in addition to the extra costs of implementing a screening programme. There is a
risk that older persons who are screened ‘out’ and are not considered ‘at risk’ (false negatives)
could suffer from neglect as a result of screening. For example, nutritional screening might
potentially result in ineffective or harmful interventions for some patients, but we found no
study that assessed such potential outcomes of the screening programmes.
Future studies should consider the different implications of ‘opportunistic screening’ versus
‘screening as part of ongoing care’. While both approaches may result in changes in referrals
to concerned health professionals, the direction of effect for the latter approach might be
different. Screening as part of ongoing primacy care service might be more likely to improve
staff awareness and might indirectly result in a reduced need for referrals. Although the
included studies do not provide enough evidence on this issue, other direct evidence suggests
that routine screening improves health professionals’ awareness of unmet care needs [31].
The rationale for promoting the screening tool is to detect targeted priority conditions in an
early—pre-symptomatic—phase and to realise better treatment outcomes by early
intervention compared to the usual care in a later—symptomatic—phase. Screening
programmes (like all healthcare services) must prove not only the effectiveness of clinical
intervention but also the economic cost-effectiveness. Over the past 20 years, decisions in the
healthcare sector have focused increasingly on health economic goals. Due to demographic
ageing and technological progress, the provision of healthcare services is characterised by an
increasing shortage of resources.
Several feasibility issues arise from this review. Many studies highlighted limitations in the
interpretation of their outcomes mainly due to selective reporting of cut-off scores that might,
on occasion, have inflated the accuracy of the tools. Moreover, several studies examining
screening tools were focused on the general adult population with no specific subgroup
analysis for older people. Studies exploring shorter versions of screening tools, such as GDS,
are currently limited, and future research should include multiple cut-off point reporting and
summary indicators of discriminability, such as the area under the ROC curve or Youden’s
Index. Similarly, a significant gap was identified in the amount of available evidence assessing
screenings for subsyndromal conditions (e.g. MCI and subthreshold depression). However,
these findings could be expected considering the scales are not specifically designed for these
conditions.
Despite a large body of well-conducted diagnostic accuracy studies, only a handful of
instruments have been studied in more than one study applicable to primary care or
community care settings. Further, the majority of studies were conducted in high-income
countries. Therefore, future research should validate the screening tool in a non-specialist
healthcare setting.
This review also found that very few screening tools are available in the public domain for
clinicians and researchers. Many validated screening tools are pulled behind a wall of active
copyright enforcement by the authors. In fact, clinical tools we take for granted, such as the
Katz Index of Independence in Activities of Daily Living, fall into the same ‘benign neglect’
copyright category as the MMSE did before 2000. We recommend that authors of widely used
clinical tools provide explicit permissive licensing, ideally with a form of copyleft. Any new tool
developed with public funds can be required to use a copyleft or similar license to guarantee
the freedom to distribute and improve it, similar to the requirement for open-access
publication of research.
Annex :
1. Glossary
Cognitive impairment: A loss or abnormality in attention functions, memory functions or higher-level cognitive functions. ■ Attention functions are special mental functions that focus on an external stimulus or internal experience for a
specific period of time ■ Memory functions are special mental functions that register and store information and retrieve it as needed ■ Higher-level cognitive functions are special mental functions that involve the frontal lobes of the brain. They
include complex goal-directed behaviours such as decision-making, abstract thinking, planning and carrying out
plans, mental flexibility, and deciding which behaviours are appropriate under specific circumstances. These are
often called executive functions
Depressive symptoms: The presence of distress or some degree of impaired functioning in the
absence of depressive episode/disorder.
Hearing impairment: The loss or abnormality in sensory functions relating to sensing the
presence of sounds and discriminating the location, pitch, loudness or quality of sounds.
Mobility impairment: A loss or abnormality in any form of moving by changing body position
or location or by transferring from one place to another, by carrying, moving or manipulating
objects, by walking, running or climbing, and by using various forms of transportation.
Vision impairment: A loss or abnormality in sensory functions relating to sensing the presence
of light and sensing the form, size, shape or colour of the visual stimuli.
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