scholarly journals An Update of the Systematic Appraisal of the Accuracy and Utility of Discography in Chronic Spinal Pain

2018 ◽  
Vol 1 (21;1) ◽  
pp. 91-110 ◽  
Author(s):  
Laxmaiah Manchikanti
Keyword(s):  
Systematic Review ◽  
Intervertebral Disc ◽  
Diagnostic Accuracy ◽  
Quality Assessment ◽  
Methodological Quality ◽  
Spinal Pain ◽  
Inclusion Criteria ◽  
Discogenic Pain ◽  
Level I ◽  
Chronic Spinal Pain

Background: The intervertebral disc has been implicated as a major cause of chronic spinal pain based on clinical, basic science, and epidemiological research. There is, however, a lack of consensus regarding the diagnosis and treatment of intervertebral disc disorders. Based on controlled evaluations, lumbar intervertebral discs have been shown to be the source of chronic back pain without disc herniation in 26% to 39% of patients, and in 16% to 53% of patients with pain in the cervical spine. Lumbar, cervical, and thoracic provocation discography, which includes disc stimulation and morphological evaluation, is often used to distinguish a painful disc from other potential sources of pain. Despite the extensive literature on point, intense debate continues about lumbar discography as a diagnostic tool. Study Design: A systematic review of the diagnostic accuracy of lumbar, cervical, and thoracic provocation and analgesic discography literature. Objective: To systematically assess and re-evaluate the diagnostic accuracy of lumbar, cervical, and thoracic discography. Methods: The available literature on discography was reviewed. A methodological quality assessment of included studies was performed using the Quality Appraisal of Reliability Studies (QAREL) checklist. Only diagnostic accuracy studies meeting at least 50% of the designated inclusion criteria were included in the analysis. To assess the level of evidence, a modified grading of qualitative evidence criteria was utilized, with grading of evidence into 5 categories from Level I to Level V incorporating evidence obtained from multiple high quality diagnostic accuracy studies for Level I and opinion or consensus of a large group of clinicians and/or scientists for Level V. Data sources included relevant literature identified through searches of PubMed and EMBASE from 1966 to June 2017, and manual searches of the bibliographies of known primary and review articles. Results: Over 100 manuscripts were considered for inclusion. Of these, 8 studies met inclusion criteria for diagnostic accuracy and prevalence with 5 studies assessing lumbar provocation discography and 3 studies assessing cervical discography. The results showed variable prevalence from 16.9% to 26% for discogenic pain and 16.9% to 42% for internal disc disruption. The cervical discogenic pain prevalence ranged from 16% to 53%. Based on methodological quality assessment criteria the strength of evidence for lumbar provocation discography is Level III and for cervical discogenic pain is Level IV. Limitations: Despite multiple publications in the lumbar spine, value and validity of discography continues to be debated. In reference to cervical and thoracic discography, the available literature and value and validity continues to be low. Conclusion: This systematic review illustrates that lumbar provocation discography performed according to the International Association for the Study of Pain (IASP) criteria may be a useful tool for evaluating chronic lumbar discogenic pain. The evidence is weaker for cervical and nonexistent for thoracic discography. Key words: Lumbar intervertebral disc, cervical intervertebral disc, thoracic intervertebral disc, discography, provocation discography, analgesic discography, diagnostic accuracy, prevalence

scholarly journals Systematic Review of Discography as a Diagnostic Test for Spinal Pain: An Update

2007 ◽  
Vol 1;10 (1;1) ◽  
pp. 147-164
Author(s):  
Ricardo M. Buenaventura
Keyword(s):  
Systematic Review ◽  
Intervertebral Disc ◽  
Diagnostic Accuracy ◽  
Spinal Pain ◽  
Evaluation Tool ◽  
Discogenic Pain ◽  
Imaging Tool ◽  
Pain Generator ◽  
Chronic Spinal Pain

Background: The intervertebral disc has been implicated as an etiology of chronic spine pain based on clinical, basic science, and epidemiological research. There is currently no way to determine with absolute certainty whether or not the disc is a spinal pain generator. At our current level of understanding, discography is thought of as the best tool to evaluate disc-related pain. Study Design: A systematic review. Objective: To systematically assess the diagnostic accuracy of discography with respect to chronic spinal pain. Methods: A systematic review of the literature was performed to assess the diagnostic accuracy of discography with respect to chronic spinal pain. Study inclusion/exclusion criteria were based on the modern practice of discography. Selected studies were then subjected to two rating instruments for diagnostic accuracy studies (AHRQ and QUADAS). Specific data were then culled from these studies and tabulated. Evidence was then classified into five levels: conclusive, strong, moderate, limited, or indeterminate. Results: Evidence is strong for the diagnostic accuracy of discography as an imaging tool. Evidence is also strong for the ability of discography to evoke pain. There is strong evidence supporting the role of discography in identifying that subset of patients with lumbar discogenic pain. There is moderate evidence supporting the role of discography in identifying a subset of patients with cervical discogenic pain. There is limited evidence supporting the role of discography in identifying a subset of patients with thoracic discogenic pain. Conclusion: Discography is a useful imaging and pain evaluation tool in identifying a subset of patients with chronic spinal pain secondary to intervertebral disc disorders. Key words: Spinal pain, intervertebral disc, discography, pain generator, false-positives, diagnostic accuracy

scholarly journals An Update of the Systematic Appraisal of the Accuracy and Utility of Lumbar Discography in Chronic Low Back Pain

2013 ◽  
Vol 2s;16 (2s;4) ◽  
pp. SE55-SE95
Author(s):  
Laxmaiah Manchikanti
Keyword(s):  
Systematic Review ◽  
Back Pain ◽  
Intervertebral Disc ◽  
Diagnostic Accuracy ◽  
Chronic Back Pain ◽  
Task Force ◽  
International Association ◽  
Extensive Literature ◽  
Discogenic Pain

Background: The intervertebral disc has been implicated as a major cause of chronic lumbar spinal pain based on clinical, basic science, and epidemiological research. There is, however, a lack of consensus regarding the diagnosis and treatment of intervertebral disc disorders. Based on controlled evaluations, lumbar intervertebral discs have been shown to be the source of chronic back pain without disc herniation in 26% to 39% of patients. Lumbar provocation discography, which includes disc stimulation and morphological evaluation, is often used to distinguish a painful disc from other potential sources of pain. Despite the extensive literature, intense debate continues about lumbar discography as a diagnostic tool. Study Design: A systematic review of the diagnostic accuracy of lumbar provocation and analgesic discography literature. Objective: To systematically assess and re-evaluate the diagnostic accuracy of lumbar discography. Methods: The available literature on lumbar discography was reviewed. A methodological quality assessment of included studies was performed using the Quality Appraisal of Reliability Studies (QAREL) checklist. Only diagnostic accuracy studies meeting at least 50% of the designated inclusion criteria were included in the analysis. However, studies scoring less than 50% are presented descriptively and critically analyzed. The level of evidence was classified as good, fair, and limited or poor based on the quality of evidence developed by the U.S. Preventive Services Task Force (USPSTF). Data sources included relevant literature identified through searches of PubMed and EMBASE from 1966 to September 2012, and manual searches of the bibliographies of known primary and review articles. Results: Over 160 studies were considered for inclusion. Of these, 33 studies compared discography with other diagnostic tests, 30 studies assessed the diagnostic accuracy of discography, 22 studies assessed surgical outcomes for discogenic pain, and 3 studies assessed the prevalence of lumbar discogenic pain. The quality of the overall evidence supporting provocation discography based on the above studies appears to be fair. The prevalence of internal disc disruption is estimated to be 39% to 42%, whereas the prevalence of discogenic pain without assessing internal disc disruption is 26%. Conclusion: This systematic review illustrates that lumbar provocation discography performed according to the International Association for the Study of Pain (IASP) criteria may be a useful tool for evaluating chronic lumbar discogenic pain. Key words: Lumbar intervertebral disc, lumbar discography, provocation discography, analgesic discography, diagnostic accuracy

scholarly journals An Update of the Appraisal of the Accuracy of Thoracic Discography as a Diagnostic Test for Chronic Spinal Pain

2012 ◽  
Vol 6;15 (6;12) ◽  
pp. E757-E776
Author(s):  
Vijay Singh
Keyword(s):  
Systematic Review ◽  
Intervertebral Disc ◽  
Diagnostic Accuracy ◽  
Facet Joint ◽  
Task Force ◽  
Relevant Literature ◽  
Thoracic Pain ◽  
Level Of Evidence ◽  
Discogenic Pain

Background: Even though the prevalence of thoracic pain has been reported to be 13% of the general population and up to 22% of the population in interventional pain management settings, the role of thoracic discs as a cause of chronic thoracic and extrathoracic pain has not been well studied. The intervertebral discs, zygapophysial or facet joints, and other structures including the costovertebral and costotransverse joints have been identified as a source of thoracic pain. Study Design: A systematic review of provocation thoracic discography. Objective: To systematically assess and update the quality of clinical studies evaluating the diagnostic accuracy of provocation thoracic discography. Methods: A systematic review of the literature was performed to assess the diagnostic accuracy of thoracic discography with respect to chronic, function limiting, thoracic or extrathoracic pain. The available literature on thoracic discography was reviewed. A methodological quality assessment of included studies was performed using Quality Appraisal of Reliability Studies (QAREL). The level of evidence was classified as good, fair, and limited (or poor) based on the quality of evidence developed by the U.S. Preventive Services Task Force (USPSTF). Data sources included relevant literature identified through searches of PubMed and EMBASE from 1966 to June 2012, and manual searches of the bibliographies of known primary and review articles. Results: The evidence and clinical value of thoracic provocation discography is limited (poor) with a paucity of evidence, with only 2 studies meeting inclusion criteria. Limitations: The limitation of this study continues to be the paucity of literature. Conclusion: Based on the available evidence for this systematic review, due to limited evidence, thoracic provocation discography is rarely recommended for the diagnosis of discogenic pain in the thoracic spine, if conservative management has failed and facet joint pain has been excluded. Key words: Thoracic pain, chest wall pain, intervertebral disc, thoracic intervertebral disc, thoracic disc herniation, discogenic pain, thoracic provocation discography, falsepositive response, diagnostic accuracy

scholarly journals Factors influencing nurses participation in the health policy-making process: a systematic review

BMC Nursing ◽  
2021 ◽  
Vol 20 (1) ◽  
Author(s):  
Alireza Hajizadeh ◽  
Vahid Zamanzadeh ◽  
Edris Kakemam ◽  
Rona Bahreini ◽  
Rahim Khodayari-Zarnaq
Keyword(s):  
Systematic Review ◽  
Health Policy ◽  
Quality Assessment ◽  
Policy Making ◽  
Methodological Quality ◽  
Health Systems Strengthening ◽  
Inclusion Criteria ◽  
Factors Influencing ◽  
Policy Making Process ◽  
Present Systematic Review

Abstract Background Nurses as the majority of the health care workforce help in the health systems strengthening. Nurses’ involvement in health policy making is clear; however, still few are involved in policy-making processes, even in the clinical context. The aim of the present systematic review was to identify factors influencing nurses participation in the health policy-making process. Methods The present systematic review was designed on studies conducted between 2000 and 2019. Four online databases including PubMed, EMBASE, SCOPUS and Science Direct were searched using comprehensive terms. Study selection, quality assessment, data extraction, and data analysis were independently done by two reviewers. Inclusion criteria included published studies in English language and between 2000 to 2019, participants such as nurses and the healthcare managers, mentioned influential factors, types of participants were included nurses and the healthcare managers, study designs and methods clearly defined. The methodological quality of included article was appraised using the checklists of CASP and MMAT. Finally the data were analyzed using content analysis. Results After quality assessment, 11 studies, according to inclusion criteria, were retrieved. Nine studies had a good, 2 a medium, and non-articles was poor methodological quality. Three main themes include nursing-related factors (4 sub- themes), management and organizational factors (8 sub-themes) and creating a positive work environment (3 sub-themes) identified as affecting factors on nurses participation in health policy. Conclusion Nurses can utilize this finding to develop empowering programs to play efficient roles and increase their participation in health policy making. Also, the extracted factors in this review can place nurses in suitable position and make them potential agents in changing the ways of policy-making. Further studies are required to survey the relation between these factors and nursing participation in health policy making.

scholarly journals An Update of the Appraisal of the Accuracy and Utility of Cervical Discography in Chronic Neck Pain

2012 ◽  
Vol 6;15 (6;12) ◽  
pp. E777-E806 ◽  
Author(s):  
Obi Onyewu
Keyword(s):  
Systematic Review ◽  
Neck Pain ◽  
Diagnostic Accuracy ◽  
Methodological Quality ◽  
Task Force ◽  
Preventive Services ◽  
Chronic Neck Pain ◽  
Accuracy Evaluation ◽  
Inclusion Criteria ◽  
Level Of Evidence

Background: Chronic neck pain represents a significant public health problem. Despite high prevalence rates, there is a lack of consensus regarding the causes or treatments for this condition. Based on controlled evaluations, the cervical intervertebral discs, facet joints, and atlantoaxial joints have all been implicated as pain generators. Cervical provocation discography, which includes disc stimulation and morphological evaluation, is occasionally used to distinguish a painful disc from other potential sources of pain. Yet in the absence of validation and controlled outcome studies, the procedure remains mired in controversy. Study Design: A systematic review of the diagnostic accuracy of cervical discography. Objective: To systematically evaluate and update the diagnostic accuracy of cervical discography. Methods: The available literature on cervical discography was reviewed. Methodological quality assessment of included studies was performed using Quality Appraisal of Reliability Studies (QAREL). Only diagnostic accuracy studies meeting at least 50% of the designated inclusion criteria were utilized for analysis. However, studies scoring less than 50% are presented descriptively and analyzed critically. The level of evidence was classified as good, fair, and limited or poor based on the quality of evidence developed by the U.S. Preventive Services Task Force (USPSTF). Data sources included relevant literature identified through searches of PubMed and EMBASE from 1966 to June 2012, and manual searches of the bibliographies of known primary and review articles. Results: A total of 41 manuscripts were considered for accuracy and utility of cervical discography in chronic neck pain. There were 23 studies evaluating accuracy of discography. There were 3 studies meeting inclusion criteria for assessing the accuracy and prevalence of discography, with a prevalence of 16% to 53%. Based on modified Agency for Healthcare Research and Quality (AHRQ) accuracy evaluation and United States Preventive Services Task Force (USPSTF) level of evidence criteria, this systematic review indicates the strength of evidence is limited for the diagnostic accuracy of cervical discography. Limitations: Limitations include a paucity of literature, poor methodological quality, and very few studies performed utilizing International Association for the Study of Pain (IASP) criteria. Conclusion: There is limited evidence for the diagnostic accuracy of cervical discography. Nevertheless, in the absence of any other means to establish a relationship between pathology and symptoms, cervical provocation discography may be an important evaluation tool in certain contexts to identify a subset of patients with chronic neck pain secondary to intervertebral disc disorders.

scholarly journals A framework for nursing participation in health policy making: a systematic review

2020 ◽  
Author(s):  
Alireza Hajizadeh ◽  
Vahid Zamanzadeh ◽  
Edris Kakemam ◽  
Rona Bahreini ◽  
rahim Khodayari-Zarnaq
Keyword(s):  
Systematic Review ◽  
Health Policy ◽  
Quality Assessment ◽  
Health Systems ◽  
Policy Making ◽  
Methodological Quality ◽  
Organizational Factors ◽  
Health Systems Strengthening ◽  
Inclusion Criteria ◽  
Present Systematic Review

Abstract Background : Nurses as the majority of the health care workforce help in the health systems strengthening. Nurses' involvement in health policy making is clear; however, still few are involved in policy-making processes, even in the clinical context. The aim of the present systematic review was to designing a framework for nursing participation in health policy making. Methods: The present systematic review was designed on studies conducted between 2000 and 2019. Four online databases including PubMed, EMBASE, SCOPUS and Science Direct were searched using comprehensive terms. Study selection, quality assessment, data extraction, and data analysis were independently done by two reviewers. Inclusion criteria included published studies in English language and between 2000 to 2019, participants such as nurses and the healthcare managers, mentioned influential factors, types of participants were included nurses and the healthcare managers, study designs and methods clearly defined. The methodological quality of included article was appraised using the checklists of CASP and MMAT. Finally, the data were analyzed using content analysis. Results: After quality assessment, 11 studies, according to inclusion criteria, were retrieved. Nine studies had a good, two a medium, and non-articles was poor methodological quality. Three main identified themes were: nursing-related factors (4 sub- themes), management and organizational factors (8 sub-themes) and creating a positive work environment (3 sub-themes). Conclusion: The designed framework in the present review can act as a facilitator of developing more participation on behalf of nursing staff in the processes of policy making about health systems. Nurses can utilize this finding to develop empowering programs to play efficient roles and increase their participation in health policy making. Further studies are required to survey the relation between these factors and nursing participation in health policy making.

scholarly journals Systematic Review of Thoracic Discography as a Diagnostic Test for Chronic Spinal Pain

2008 ◽  
Vol 5;11 (10;5) ◽  
pp. 631-642
Author(s):  
Vijay Singh
Keyword(s):  
Systematic Review ◽  
Intervertebral Disc ◽  
Diagnostic Accuracy ◽  
The United States ◽  
Facet Joints ◽  
Thoracic Pain ◽  
Level Of Evidence ◽  
Discogenic Pain ◽  
Weak Recommendation ◽  
Methodologic Quality

Background: Even though the prevalence of thoracic pain has been reported to be 15% of the general population and up to 22% of the population in interventional pain management settings, the role of thoracic discs as a cause of chronic thoracic and extrathoracic pain has not been well researched. The intervertebral discs, zygapophysial or facet joints, and other structures including the costovertebral and costotransverse joints have been identified as a source of thoracic pain. Objective: To systematically assess the quality of clinical studies evaluating the diagnostic accuracy of provocation thoracic discography. Study Design: A systematic review of provocation thoracic discography. Methods: A systematic review of the literature was performed to assess the diagnostic accuracy of thoracic discography with respect to chronic, function limiting, thoracic or extrathoracic pain. Studies meeting the Agency for Healthcare Research and Quality (AHRQ) methodologic quality criteria with scores of 50 or higher were included for the assessment of the level of evidence. Level of evidence was based on the United States Preventive Services Task Force (USPSTF) criteria for the assessment of accuracy of diagnostic studies. Based on the level of evidence, recommendations were made according to Guyatt et al’s criteria. Results: The clinical value of thoracic provocation discography is limited (Level II-3) with 2C/weak recommendation derived from low quality or very low quality evidence indicating that other alternatives may be equally reasonable. Conclusion: Based on the available evidence for this systematic review, thoracic provocation discography is provided with a weak recommendation for the diagnosis of discogenic pain in the thoracic spine, if conservative management has failed. This is qualified by the need to appropriately evaluate and diagnose other causes of chronic thoracic pain including pain originating from thoracic facet joints. Key words: Thoracic pain, chest wall pain, intervertebral disc, thoracic intervertebral disc, facet joint, thoracic disc herniation, discogenic pain, lumbar provocation discography, cervical provocation discography, thoracic provocation discography, false-positive response, diagnostic accuracy

scholarly journals Test characteristics of history, examination and investigations in the evaluation for septic arthritis in the child presenting with acute non-traumatic limp. A systematic review

BMJ Open ◽  
2020 ◽  
Vol 10 (12) ◽  
pp. e038088
Author(s):  
Jacky Tu ◽  
Peter Gowdie ◽  
Julian Cassar ◽  
Simon Craig
Keyword(s):  
Systematic Review ◽  
Diagnostic Accuracy ◽  
Septic Arthritis ◽  
Quality Assessment ◽  
Likelihood Ratio ◽  
Risk Prediction ◽  
Positive Likelihood Ratio ◽  
Negative Likelihood Ratio ◽  
Prediction Tools ◽  
Clinical Risk

BackgroundSeptic arthritis is an uncommon but potentially significant diagnosis to be considered when a child presents to the emergency department (ED) with non-traumatic limp. Our objective was to determine the diagnostic accuracy of clinical findings (history and examination) and investigation results (pathology tests and imaging) for the diagnosis of septic arthritis among children presenting with acute non-traumatic limp to the ED.MethodsSystematic review of the literature published between 1966 and June 2019 on MEDLINE and EMBASE databases. Studies were included if they evaluated children presenting with lower limb complaints and evaluated diagnostic performance of items from history, physical examination, laboratory testing or radiological examination. Data were independently extracted by two authors, and quality assessment was performed using the Quality Assessment Tool for Diagnostic Accuracy Studies 2 tool.Results18 studies were identified, and included 2672 children (560 with a final diagnosis of septic arthritis). There was substantial heterogeneity in inclusion criteria, study setting, definitions of specific variables and the gold standard used to confirm septic arthritis. Clinical and investigation findings were reported using varying definitions and cut-offs, and applied to differing study populations. Spectrum bias and poor-to-moderate study design quality limit their applicability to the ED setting.Single studies suggest that the presence of joint tenderness (n=189; positive likelihood ratio 11.4 (95% CI 5.9 to 22.0); negative likelihood ratio 0.2 (95% CI 0.0 to 1.2)) and joint effusion on ultrasound (n=127; positive likelihood ratio 8.4 (95% CI 4.1 to 17.1); negative likelihood ratio 0.2 (95% CI 0.1 to 0.3)) appear to be useful. Two promising clinical risk prediction tools were identified, however, their performance was notably lower when tested in external validation studies.DiscussionDifferentiating children with septic arthritis from non-emergent disorders of non-traumatic limp remains a key diagnostic challenge for emergency physicians. There is a need for prospectively derived and validated ED-based clinical risk prediction tools.

scholarly journals The influence of orthodontic fixed appliances on the oral microbiota: A systematic review

2014 ◽  
Vol 19 (2) ◽  
pp. 46-55 ◽  
Author(s):  
Amanda Osório Ayres de Freitas ◽  
Mariana Marquezan ◽  
Matilde da Cunha Gonçalves Nojima ◽  
Daniela Sales Alviano ◽  
Lucianne Cople Maia
Keyword(s):  
Systematic Review ◽  
Methodological Quality ◽  
Data Extraction ◽  
Scientific Evidence ◽  
Statistical Treatment ◽  
Fusobacterium Nucleatum ◽  
Oral Microbiota ◽  
Periodontal Pathogens ◽  
Inclusion Criteria ◽  
Fixed Appliances

Objective: To investigate whether there is scientific evidence to support the hypothesis that the presence of orthodontic fixed appliances influences the oral microbiota. Methods: The search for articles was conducted in PubMed; ISI Web of Knowledge and Ovid databases, including articles published in English until May 17th, 2012. They should report human observational studies presenting the following keywords: "fixed orthodontic appliance" AND "microbiological colonization"; OR "periodontal pathogens"; OR "Streptococcus"; OR "Lactobacillus"; OR "Candida"; OR "Tannerella forsythia"; OR "Treponema denticola"; OR "Fusobacterium nucleatum"; OR "Actimomyces actinomycetemcomitans"; OR "Prevotella intermedia", OR "Prevotella nigrescens"; OR "Porphyromonas gingivalis". Articles were previously selected by title and abstract. Articles that met the inclusion criteria were analyzed and classified as having low, moderate or high methodology quality. A new detailed checklist for quality assessment was developed based on the information required for applicable data extraction for reviews. The study design, sample, follow-up period, collection and microbial analysis methods, statistical treatment, results and discussion were assessed. Results: The initial search retrieved 305 articles of which 33 articles were selected by title and abstract. After full-text reading, 8 articles met the inclusion criteria, out of which 4 articles were classified as having low and 4 as moderate methodological quality. The moderate methodological quality studies were included in the systematic review. Conclusions: The literature revealed moderate evidence that the presence of fixed appliances influences the quantity and quality of oral microbiota.

scholarly journals Impact of Adjustment for Quality on Results of Metaanalyses of Diagnostic Accuracy

2007 ◽  
Vol 53 (2) ◽  
pp. 164-172 ◽  
Author(s):  
Mariska Leeflang ◽  
Johannes Reitsma ◽  
Rob Scholten ◽  
Anne Rutjes ◽  
Marcello Di Nisio ◽  
...  
Keyword(s):  
Diagnostic Accuracy ◽  
Quality Assessment ◽  
Confidence Intervals ◽  
Systematic Reviews ◽  
Methodological Quality ◽  
Patient Characteristics ◽  
Clinical Decision ◽  
High Quality ◽  
Poor Reporting

Abstract Background: We examined whether and to what extent different strategies of defining and incorporating quality of included studies affect the results of metaanalyses of diagnostic accuracy. Methods: We evaluated the methodological quality of 487 diagnostic-accuracy studies in 30 systematic reviews with the QUADAS (Quality Assessment of Diagnostic-Accuracy Studies) checklist. We applied 3 strategies that varied both in the definition of quality and in the statistical approach to incorporate the quality-assessment results into metaanalyses. We compared magnitudes of diagnostic odds ratios, widths of their confidence intervals, and changes in a hypothetical clinical decision between strategies. Results: Following 2 definitions of quality, we concluded that only 70 or 72 of 487 studies were of “high quality”. This small number was partly due to poor reporting of quality items. None of the strategies for accounting for differences in quality led systematically to accuracy estimates that were less optimistic than ignoring quality in metaanalyses. Limiting the review to high-quality studies considerably reduced the number of studies in all reviews, with wider confidence intervals as a result. In 18 reviews, the quality adjustment would have resulted in a different decision about the usefulness of the test. Conclusions: Although reporting the results of quality assessment of individual studies is necessary in systematic reviews, reader wariness is warranted regarding claims that differences in methodological quality have been accounted for. Obstacles for adjusting for quality in metaanalyses are poor reporting of design features and patient characteristics and the relatively low number of studies in most diagnostic reviews.

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