Variation in sensitivity and specificity of diverse diagnostic tests across healthcare settings: a meta-epidemiological study

Journal article

Objective: Diagnostic test accuracy may vary among healthcare settings, which among other reasons may be due to referral from primary to secondary care. The true magnitude and direction of any difference is not certain. We analyzed the results of meta-analyses of diagnostic test accuracy to compare sensitivity and specificity between patients in non-referred and referred care settings.

Study design and Setting: We systematically searched EBSCOhost MEDLINE for systematic reviews that included at least ten original studies of the same diagnostic test, with at least three studies each performed in non-referred and referred care. Random-effects models, with setting as a binary covariate, were used to calculate pooled sensitivity and specificity estimates per test. Sensitivity analyses were conducted limiting the analyses to studies from countries with gatekeeping systems only.

Results: In total, nine systematic reviews evaluating thirteen diagnostic tests were included. For signs and symptoms (seven tests), the differences in sensitivity and specificity ranged from +0.03 to +0.30 and from -0.12 to +0.03, respectively; for biomarkers (three tests) differences in sensitivity ranged from -0.11 to +0.21 and specificity from -0.01 to -0.19. Differences in sensitivity and specificity for one questionnaire test were +0.1 and -0.07 respectively and for one imaging test were -0.22 and -0.07. Sensitivity analyses limited to countries with gatekeeping health care systems produced similar results.

Conclusion: Sensitivity and specificity vary in both direction and magnitude between non-referred and referred settings, depending on the test and target condition, with no universal patterns governing performance differences.

Authors: Vijfschagt, N; Burger, H; Berger, M; Fanshawe, T; Van den Bruel, A

• Publication status: Published
• Peer review status: Peer reviewed
• Publisher: Elsevier
• Journal: Journal of Clinical Epidemiology
• Article number: 111816
• Publication date: 2025-05-06
• Acceptance date: 2025-04-29
• DOI: 10.1016/j.jclinepi.2025.111816
• EISSN: 1878-5921
• ISSN: 0895-4356
• Language: English
• Keywords: sensitivity and specificity; ultrasound; diagnostic tests; secondary care centers; primary health care