Communicating Risk: Developing an "Efficiency Index" for Dementia Screening Tests

Abstract

Diagnostic and screening tests may have risks such as misdiagnosis, as well as the potential benefits of correct diagnosis. Effective communication of this risk to both clinicians and patients can be problematic. The purpose of this study was to develop a metric called the "efficiency index" (EI), defined as the ratio of test accuracy and inaccuracy, to evaluate screening tests for dementia. This measure was compared with a previously described "likelihood to be diagnosed or misdiagnosed" (LDM), also based on "numbers needed" metrics. Datasets from prospective pragmatic test accuracy studies examining four brief cognitive screening instruments (Mini-Mental State Examination; Montreal Cognitive Assessment; Mini-Addenbrooke's Cognitive Examination (MACE); and Free-Cog) were analysed to calculate values for EI and LDM, and to examine their variation with test cut-off for MACE and dementia prevalence. EI values were also calculated using a modification of McGee's heuristic for the simplification of likelihood ratios to estimate percentage change in diagnostic probability. The findings indicate that EI is easier to calculate than LDM and, unlike LDM, may be classified either qualitatively or quantitatively in a manner similar to likelihood ratios. EI shows the utility or inutility of diagnostic and screening tests, illustrating the inevitable trade-off between diagnosis and misdiagnosis. It may be a useful metric to communicate risk in a way that is easily intelligible for both clinicians and patients.

Keywords: dementia; diagnosis; efficiency index; risk communication; screening test.

Figure 1

Standard 2 × 2 contingency table for diagnostic or screening test accuracy studies and formulae for paired measures.

Figure 2

Plot of efficiency index (EI; upper line, triangles) and of likelihood to be diagnosed or misdiagnosed (LDM; lower line, diamonds) values (y axis) vs. MACE cut-off score (x-axis).

Figure 3

Plot of efficiency index (EI; upper line, triangles) and of likelihood to be diagnosed or misdiagnosed (LDM; lower line, diamonds) values (y axis) vs. prevalence of dementia (x-axis).