An empirical comparison of statistical methods for multiple cut-off diagnostic test accuracy meta-analysis of the Edinburgh postnatal depression scale (EPDS) depression screening tool using published results vs individual participant data
Authors: Negeri Zelalem F. , Levis Brooke , Ioannidis John P. A. , Thombs Brett D. , Benedetti Andrea ,   the DEPRESsion Screening Data (DEPRESSD) EPDS Group, Sun Ying , He Chen , Krishnan Ankur , Wu Yin , Bhandari Parash Mani , Neupane Dipika , Imran Mahrukh , Rice Danielle B. , Azar Marleine , Chiovitti Matthew J. , Riehm Kira E. , Boruff Jill T. , Cuijpers Pim , Gilbody Simon , Kloda Lorie A. , Patten Scott B. , Ziegelstein Roy C. , Markham Sarah , Comeau Liane , Mitchell Nicholas D. , Vigod Simone N. , Bakare Muideen O. , Beck Cheryl Tatano , Bunevicius Adomas , Couto Tiago Castro e , Chorwe-Sungani Genesis , Favez Nicolas , Field Sally , Garcia-Esteve Lluïsa , Honikman Simone , Khalifa Dina Sami , Kohlhoff Jane , Kusminskas Laima , Kozinszky Zoltán , Nakić Radoš Sandra , Pawlby Susan J. , Rochat Tamsen J. , Sharp Deborah J. , Smith-Nielsen Johanne , Su Kuan-Pin , Tadinac Meri , Tandon S. Darius , Thiagayson Pavaani , Töreki Annamária , Torres-Giménez Anna , van Heyningen Thandi , Vega-Dienstmaier Johann M. 
Published: February 2024

Abstract
Background
Selective reporting of results from only well-performing cut-offs leads to biased estimates of accuracy in primary studies of questionnaire-based screening tools and in meta-analyses that synthesize results. Individual participant data meta-analysis (IPDMA) of sensitivity and specificity at each cut-off via bivariate random-effects models (BREMs) can overcome this problem. However, IPDMA is laborious and depends on the ability to successfully obtain primary datasets, and BREMs ignore the correlation between cut-offs within primary studies.

Methods
We compared the performance of three recent multiple cut-off models developed by Steinhauser et al., Jones et al., and Hoyer and Kuss, that account for missing cut-offs when meta-analyzing diagnostic accuracy studies with multiple cut-offs, to BREMs fitted at each cut-off. We used data from 22 studies of the accuracy of the Edinburgh Postnatal Depression Scale (EPDS; 4475 participants, 758 major depression cases). We fitted each of the three multiple cut-off models and BREMs to a dataset with results from only published cut-offs from each study (published data) and an IPD dataset with results for all cut-offs (full IPD data). We estimated pooled sensitivity and specificity with 95% confidence intervals (CIs) for each cut-off and the area under the curve.

Results
Compared to the BREMs fitted to the full IPD data, the Steinhauser et al., Jones et al., and Hoyer and Kuss models fitted to the published data produced similar receiver operating characteristic curves; though, the Hoyer and Kuss model had lower area under the curve, mainly due to estimating slightly lower sensitivity at lower cut-offs. When fitting the three multiple cut-off models to the full IPD data, a similar pattern of results was observed. Importantly, all models had similar 95% CIs for sensitivity and specificity, and the CI width increased with cut-off levels for sensitivity and decreased with an increasing cut-off for specificity, even the BREMs which treat each cut-off separately.

Conclusions
Multiple cut-off models appear to be the favorable methods when only published data are available. While collecting IPD is expensive and time consuming, IPD can facilitate subgroup analyses that cannot be conducted with published data only.