The Montreal Cognitive Assessment (MoCA) with a double threshold: improving the MoCA for triaging patients in need of a neuropsychological assessment.

OBJECTIVES: Diagnosis of patients suspected of mild dementia (MD) is a challenge and patient numbers continue to rise. A short test triaging patients in need of a neuropsychological assessment (NPA) is welcome. The Montreal cognitive assessment (MoCA) has high sensitivity at the original cutoff <26 for MD, but results in too many false-positive (FP) referrals in clinical practice (low specificity). A cutoff that finds all patients at high risk of MD without referring to many patients not (yet) in need of an NPA is needed. A difficulty is who is to be considered at risk, as definitions for disease (e.g. MD) do not always define health at the same time and thereby create subthreshold disorders. DESIGN: In this study, we compared different selection strategies to efficiently identify patients in need of an NPA. Using the MoCA with a double threshold tackles the dilemma of increasing the specificity without decreasing the sensitivity and creates the opportunity to distinguish the clinical (MD) and subclinical (MCI) state and hence to get their appropriate policy. SETTING/PARTICIPANTS: Patients referred to old-age psychiatry suspected of cognitive impairment that could benefit from an NPA (n = 693). RESULTS: The optimal strategy was a two-stage selection process using the MoCA with a double threshold as an add-on after initial assessment. By selecting who is likely to have dementia and should be assessed further (MoCA<21), who should be discharged (≥26), and who's course should be monitored actively as they are at increased risk (21<26). CONCLUSION: By using two cutoffs, the clinical value of the MoCA improved for triaging. A double-threshold MoCA not only gave the best results; accuracy, PPV, NPV, and reducing FP referrals by 65%, still correctly triaging most MD patients. It also identified most MCIs whose intermediate state justifies active monitoring.

Evaluation of opening a type III/IV medical psychiatric unit.

OBJECTIVE: The aim of this study is to examine the impact of opening a medical psychiatric unit (MPU) on a variety of outcomes. METHODS: In this non-equivalent groups design, there were two groups: 'pre-MPU' and 'actual MPU'. Staff assessed whether patients in the pre-MPU group were eligible for admission to a planned MPU, resulting in virtual admissions and discharges. The actual MPU group consisted of patients admitted after opening of the MPU. RESULTS: The length of stay (LOS) in the hospital was one day longer for patients in the MPU group (8.68 vs. 9.89, p = .004), but the LOS on the MPU was comparable in both groups (5.63 vs. 6.06, p = .231). The LOS on the intensive care unit (ICU) was longer in the MPU group (0.10 vs. 0.40, p < .001), even as the time patients were physically restraint (0.28 vs. 0.83, p < .001). In the pre-MPU group, the odds were not significantly different for involuntary commitment (OR = 0.92; p = .866) and death within six months after discharge (OR = 1.84; p = .196). CONCLUSIONS: Both physical restraint and ICU admission have a link with patient complexity, it therefore seemed that opening of the MPU resulted in the treatment of more complex patients with a comparable LOS on the MPU.KEY POINTSThe LOS on the MPU was not significantly different between the groups before and after opening of the MPU.Opening of the MPU resulted in the admission of patients that were admitted more days to the ICU and to more days of physically restraint.It can be considered that opening of the MPU resulted in an increased ability to treat complex patients.

Clinical value of the Montreal Cognitive Assessment (MoCA) in patients suspected of cognitive impairment in old age psychiatry. Using the MoCA for triaging to a memory clinic.

Objectives: Diagnostic pathways are limited. A validated instrument that can triage patients when they are suspected of mild dementia (MD) is necessary to optimise referrals. Method: The MoCA is validated for identifying MD and mild cognitive impairment (MCI) in a cohort of patients suspected of cognitive impairment (CI) after initial assessment in old age psychiatry. The reference standard was the consensus-based diagnoses for MD and MCI, adhering to the international criteria and using suspected patients, but without CI as comparisons (NoCI). Results: The mean MoCA scores differ significantly between the groups: 24(SE: .59) in NoCI, 21(SE: .31) in MCI and 16,7(SE: .45) in MD (p < .05). The AUC of MD against non-demented (MCI + NoCI) was 0.83(95%CI: 0.78-0.88) resulting in 90% sensitivity, 65% specificity, 50%PPV and 94%NPV at a "best" cutoff of <21 according the Youden index and respectively 0.77(95%CI: 0.69-0.85), 56%, 73%, 90%, 28% for CI (MD + MCI) against NoCI at <21. Conclusion: 90% of individuals with a MoCA of <21 will have CI (MD + MCI), while 94% with a MoCA of ≥21 will not have dementia. The MoCA can reduce referrals substantially (50%) by selecting who don't need further work up in a memory clinic, even if they were suspected of CI after initial assessment.

Diagnostic accuracy of the Montreal Cognitive Assessment (MoCA) for cognitive screening in old age psychiatry: Determining cutoff scores in clinical practice. Avoiding spectrum bias caused by healthy controls.

OBJECTIVE/METHODS: The Montreal Cognitive Assessment (MoCA) is an increasingly used screening tool for cognitive impairment. While it has been validated in multiple settings and languages, most studies have used a biased case-control design including healthy controls as comparisons not representing a clinical setting. The purpose of the present cross-sectional study is to test the criterion validity of the MoCA for mild cognitive impairment (MCI) and mild dementia (MD) in an old age psychiatry cohort (n = 710). The reference standard consists of a multidisciplinary, consensus-based diagnosis in accordance with international criteria. As a secondary outcome, the use of healthy community older adults as additional comparisons allowed us to underscore the effects of case-control spectrum-bias. RESULTS: The criterion validity of the MoCA for cognitive impairment (MCI + MD) in a case-control design, using healthy controls, was satisfactory (area under the curve [AUC] 0.93; specificity of 73% less than 26), but declined in the cross-sectional design using referred but not cognitive impaired as comparisons (AUC 0.77; specificity of 37% less than 26). In an old age psychiatry setting, the MoCA is valuable for confirming normal cognition (greater than or equal to 26, 95% sensitivity), excluding MD (greater than or equal to 21; negative predictive value [NPV] 98%) and excluding MCI (greater than or equal to 26;NPV 94%); but not for diagnosing MD (less than 21; positive predictive value [PPV] 31%) or MCI (less than 26; PPV 33%). CONCLUSIONS: This study shows that validating the MoCA using healthy controls overestimates specificity. Taking clinical and demographic characteristics into account, the MoCA is a suitable screening tool-in an old age psychiatry setting-for distinguishing between those in need of further diagnostic investigations and those who are not but not for diagnosing cognitive impairment.

Identifying value-based quality indicators for general hospital psychiatry.

OBJECTIVE: To define generic quality indicators for general hospital psychiatry from the perspectives of patients, professionals (physicians, nurses, and managers), and payers (health insurance companies). METHODS: Quality variables were identified by reviewing the relevant literature. A working. group consisting of patients', professionals' and payers' representatives was mandated by their respective umbrella organizations. The working group prioritized the quality variables that were identified. Core values were defined and subsequently linked to preliminary quality indicators. These were tested for feasibility in ten hospitals in a four-week period. Stakeholder consultation took place by means of two invitational conferences and two written commentary rounds. RESULTS: Forty-one quality variables were identified from the literature. After prioritization, seven core values were defined and translated to 22 preliminary indicators. Overall, the feasibility study showed high relevance scores and good implementability of the preliminary quality indicators. A final set of twenty-two quality indicators (17 structure, 3 process and 2 outcome indicators) was then established using a consensus-based approach. CONCLUSION: Consensus on a quality framework for general hospital psychiatry was built by incorporating the perspectives of relevant stakeholders. Results of the feasibility study suggest broad support and good implementability of the final quality indicators. Structural indicators were broadly defined, and process and outcome indicators are generic to facilitate quality measurement across settings. The quality indicator set can now be used to facilitate quality and outcome assessment, stimulate standardization of services, and help demonstrate (cost-) effectiveness.

STARD 2015: An Updated List of Essential Items for Reporting Diagnostic Accuracy Studies.

Incomplete reporting has been identified as a major source of avoidable waste in biomedical research. Essential information is often not provided in study reports, impeding the identification, critical appraisal, and replication of studies. To improve the quality of reporting of diagnostic accuracy studies, the Standards for Reporting of Diagnostic Accuracy Studies (STARD) statement was developed. Here we present STARD 2015, an updated list of 30 essential items that should be included in every report of a diagnostic accuracy study. This update incorporates recent evidence about sources of bias and variability in diagnostic accuracy and is intended to facilitate the use of STARD. As such, STARD 2015 may help to improve completeness and transparency in reporting of diagnostic accuracy studies.

STARD 2015: An Updated List of Essential Items for Reporting Diagnostic Accuracy Studies.

Incomplete reporting has been identified as a major source of avoidable waste in biomedical research. Essential information is often not provided in study reports, impeding the identification, critical appraisal, and replication of studies. To improve the quality of reporting of diagnostic accuracy studies, the Standards for Reporting of Diagnostic Accuracy Studies (STARD) statement was developed. Here we present STARD 2015, an updated list of 30 essential items that should be included in every report of a diagnostic accuracy study. This update incorporates recent evidence about sources of bias and variability in diagnostic accuracy and is intended to facilitate the use of STARD. As such, STARD 2015 may help to improve completeness and transparency in reporting of diagnostic accuracy studies.

Pharmacological treatment for psychotic depression.

BACKGROUND: Evidence is limited regarding the most effective pharmacological treatment for psychotic depression: combination of an antidepressant plus an antipsychotic, monotherapy with an antidepressant or monotherapy with an antipsychotic. This is an update of a review first published in 2005 and last updated in 2009. OBJECTIVES: 1. To compare the clinical efficacy of pharmacological treatments for patients with an acute psychotic depression: antidepressant monotherapy, antipsychotic monotherapy and the combination of an antidepressant plus an antipsychotic, compared with each other and/or with placebo.2. To assess whether differences in response to treatment in the current episode are related to non-response to prior treatment. SEARCH METHODS: A search of the Cochrane Central Register of Controlled Trials and the Cochrane Depression, Anxiety and Neurosis Group Register (CCDANCTR) was carried out (to 12 April 2013). These registers include reports of randomised controlled trials from the following bibliographic databases: EMBASE (1970-), MEDLINE (1950-) and PsycINFO (1960-). Reference lists of all studies and related reviews were screened and key authors contacted. SELECTION CRITERIA: All randomised controlled trials (RCTs) that included participants with acute major depression with psychotic features, as well as RCTs consisting of participants with acute major depression with or without psychotic features, that reported separately on the subgroup of participants with psychotic features. DATA COLLECTION AND ANALYSIS: Two review authors independently extracted data and assessed risk of bias in the included studies, according to the criteria of the Cochrane Handbook for Systematic Reviews of Interventions. Data were entered into RevMan 5.1. We used intention-to-treat data. For dichotomous efficacy outcomes, the risk ratio (RR) with 95% confidence intervals (CIs) was calculated. For continuously distributed outcomes, it was not possible to extract data from the RCTs. Regarding the primary outcome of harm, only overall dropout rates were available for all studies. MAIN RESULTS: The search identified 3659 abstracts, but only 12 RCTs with a total of 929 participants could be included in the review. Because of clinical heterogeneity, few meta-analyses were possible. The main outcome was reduction of severity (response) of depression, not of psychosis.We found no evidence for the efficacy of monotherapy with an antidepressant or an antipsychotic.However, evidence suggests that the combination of an antidepressant plus an antipsychotic is more effective than antidepressant monotherapy (three RCTs; RR 1.49, 95% CI 1.12 to 1.98, P = 0.006), more effective than antipsychotic monotherapy (four RCTs; RR 1.83, 95% CI 1.40 to 2.38, P = 0.00001) and more effective than placebo (two identical RCTs; RR 1.86, 95% CI 1.23 to 2.82, P = 0.003).Risk of bias is considerable: there were differences between studies with regard to diagnosis, uncertainties around randomisation and allocation concealment, differences in treatment interventions (pharmacological differences between the various antidepressants and antipsychotics) and different outcome criteria. AUTHORS' CONCLUSIONS: Psychotic depression is heavily understudied, limiting confidence in the conclusions drawn. Some evidence indicates that combination therapy with an antidepressant plus an antipsychotic is more effective than either treatment alone or placebo. Evidence is limited for treatment with an antidepressant alone or with an antipsychotic alone.

Pharmacological treatment for psychotic depression.

BACKGROUND: Evidence is limited regarding the most effective pharmacological treatment for psychotic depression: combination of an antidepressant plus an antipsychotic, monotherapy with an antidepressant or monotherapy with an antipsychotic. This is an update of a review first published in 2005 and last updated in 2009. OBJECTIVES: 1. To compare the clinical efficacy of pharmacological treatments for patients with an acute psychotic depression: antidepressant monotherapy, antipsychotic monotherapy and the combination of an antidepressant plus an antipsychotic, compared with each other and/or with placebo.2. To assess whether differences in response to treatment in the current episode are related to non-response to prior treatment. SEARCH METHODS: A search of the Cochrane Central Register of Controlled Trials and the Cochrane Depression, Anxiety and Neurosis Group Register (CCDANCTR) was carried out (to 12 April 2013). These registers include reports of randomised controlled trials from the following bibliographic databases: EMBASE (1970-), MEDLINE (1950-) and PsycINFO (1960-). Reference lists of all studies and related reviews were screened and key authors contacted. SELECTION CRITERIA: All randomised controlled trials (RCTs) that included participants with acute major depression with psychotic features, as well as RCTs consisting of participants with acute major depression with or without psychotic features, that reported separately on the subgroup of participants with psychotic features. DATA COLLECTION AND ANALYSIS: Two review authors independently extracted data and assessed risk of bias in the included studies, according to the criteria of the Cochrane Handbook for Systematic Reviews of Interventions. Data were entered into RevMan 5.1. We used intention-to-treat data. For dichotomous efficacy outcomes, the risk ratio (RR) with 95% confidence intervals (CIs) was calculated. For continuously distributed outcomes, it was not possible to extract data from the RCTs. Regarding the primary outcome of harm, only overall dropout rates were available for all studies. MAIN RESULTS: The search identified 3659 abstracts, but only 12 RCTs with a total of 929 participants could be included in the review. Because of clinical heterogeneity, few meta-analyses were possible. The main outcome was reduction of severity (response) of depression, not of psychosis.We found no evidence for the efficacy of monotherapy with an antidepressant or an antipsychotic.However, evidence suggests that the combination of an antidepressant plus an antipsychotic is more effective than antidepressant monotherapy (three RCTs; RR 1.49, 95% CI 1.12 to 1.98, P = 0.006), more effective than antipsychotic monotherapy (four RCTs; RR 1.83, 95% CI 1.40 to 2.38, P = 0.00001) and more effective than placebo (two identical RCTs; RR 1.86, 95% CI 1.23 to 2.82, P = 0.003).Risk of bias is considerable: there were differences between studies with regard to diagnosis, uncertainties around randomisation and allocation concealment, differences in treatment interventions (pharmacological differences between the various antidepressants and antipsychotics) and different outcome criteria. AUTHORS' CONCLUSIONS: Psychotic depression is heavily understudied, limiting confidence in the conclusions drawn. Some evidence indicates that combination therapy with an antidepressant plus an antipsychotic is more effective than either treatment alone or placebo. Evidence is limited for treatment with an antidepressant alone or with an antipsychotic alone.

Red blood cell polyunsaturated fatty acids measured in red blood cells and schizophrenia: a meta-analysis.

Alterations of polyunsaturated fatty acids (PUFA) in schizophrenia have been reported, but there is substantial variation in the findings. We performed a systematic review and meta-analysis for docosapentaenoic acid (DPA), docosahexaenoic acid (DHA), linoleic acid (LA), and arachidonic acid (AA). We identified 18 studies which compared PUFA in the erythrocyte cell membrane between patients with schizophrenia and controls. A total of 642 patients (169 were antipsychotic-naïve) and 574 controls participated in these studies. We found suggestive evidence that the levels of DPA (C22:5n3) and DHA (C22:6n3) are decreased both in patients currently being treated with antipsychotic medication and antipsychotic-naïve patients. Our findings furthermore suggest that the levels of LA (C18:2n6) are decreased in the medicated subgroup, but not in the antipsychotic-naive group. Finally, we found decreased levels of AA (C20:4n6), most convincingly in antipsychotic-naive patients. Taken together, there is substantial evidence that decreased levels of DPA (C22:5n3), DHA (C22:6n3), and AA (C20:4n6) are associated with the schizophrenia syndrome, apart from a possible influence of antipsychotic medication. Given the large heterogeneity in results, these conclusions should be interpreted cautiously.

Quality of life and academic functioning 6 years after paediatric referral for chronic pain.

AIM: To assess health-related quality of life (HR-QoL) and academic functioning in adolescents and young adults 6 years after paediatric referral for chronic pain. METHODS: In 99 children and adolescents with chronic pain (aged 8-17) referred to a paediatric outpatient clinic, pain and psychiatric disorders were assessed between 2000 and 2002. Participants were reassessed after minimal 5 years (aged 13-24). HR-QoL [Medical Outcomes Study 36-item Short-Form (SF-36)] was compared with Dutch population norms. Academic functioning (structured questionnaire) was compared with baseline. RESULTS: Participant's ratings in most HR-QoL dimensions did not differ from population norms. Outcome was significantly decreased in Bodily Pain (p = 0.001 males, p < 0.000 females) and female General Health (p = 0.001). Poor general health perceptions (p = 0.002), poor global general health (p = 0.003) and a high somatic symptom level (p = 0.004) at baseline predicted poor HR-QoL outcome. School/work attendance was significantly better than at baseline (p = 0.002). CONCLUSION: Six years after paediatric referral for chronic pain, HR-QoL was mostly comparable to that of peers, and academic functioning improved. Self-evaluated global health at referral may be an important predictor of HR-QoL outcome of children with chronic pain, rather than psychiatric comorbidity.

The course of chronic pain with and without psychiatric disorders: a 6-year follow-up study from childhood to adolescence and young adulthood.

OBJECTIVE: Psychiatric disorders are common in children with chronic pain, but their course and impact when children grow up are unknown. This study examines the 6-year clinical outcome of children referred for chronic pain with and without comorbid psychiatric disorders. METHOD: In 91 children and adolescents (aged 8 to 17 years) referred to a university outpatient clinic for chronic pain, child psychiatric disorders were assessed using the Diagnostic Interview Schedule for Children-parent version (DISC-P) between 2000 and 2002. Participants (aged 13 to 24 years) were reassessed on average 6-years later. Outcome measures were chronic pain and psychiatric disorders assessed with the Diagnostic Interview Schedule for Children-children version (DISC-C) or the Composite International Diagnostic Interview (CIDI) and Diagnostic Interview Schedule IV (DIS). RESULTS: After 6 years, 75% of the participants still experienced chronic pain and 15% were in complete remission of both chronic pain and psychiatric disorder. The prevalence of psychiatric disorders (both persistent and new onset disorders) at follow-up was 32%. Baseline psychiatric disorder was a predictor of psychiatric disorder at follow-up (OR = 2.6, 95% CI = 1.1-6.5, P = .04; adjusted OR = 2.8, 95% CI = 1.1-7.1, P = .03) but did not predict persistence of chronic pain. CONCLUSIONS: Children referred for chronic pain frequently continue to suffer from chronic pain and psychiatric disorders in adolescence and young adulthood. In this population, comorbid psychiatric disorder at study entry was a predictor of psychiatric disorder, but not of persistent chronic pain, in adolescence and young adulthood.

Impaired neuroendocrine and immune response to acute stress in medication-naive patients with a first episode of psychosis.

Little is known about how the biological stress response systems--the autonomic nervous system (ANS), the hypothalamic-pituitary-adrenal (HPA) axis, and the immune system--function during psychosis. Results of studies on the effect of stress on the immune and autonomic system in patients with schizophrenia are inconsistent. The present study investigates whether the stress response is impaired in medication-naive patients with a first episode of psychosis. Ten male patients with a first episode of psychosis and 15 controls were exposed to the stress of public speaking. Parameters of the ANS (heart rate and catecholamines), the HPA axis (plasma adrenocorticotropic hormone [ACTH] and cortisol), and the immune system (number and activity of natural killer [NK] cells) were measured. Peak responses were calculated to examine the relationship between stress-induced activation of the different systems. Subjective stress and anxiety before and during the task were assessed. Patients and controls displayed similar autonomic responses to acute stress. However, there was an impaired HPA axis response, slow onset and return of ACTH, and flattened cortisol response and a reduced increase in number NK cells and NK cell activity in patients with a first episode of psychosis. Furthermore, in patients, the relationship between the different stress response systems was weaker or absent compared with controls. These findings indicate that impairments in stress processing are associated with the endophenotype of psychosis and are not a result of illness progression or antipsychotic medication.

Proposals for a phased evaluation of medical tests.

BACKGROUND: In drug development, a 4-phase hierarchical model for the clinical evaluation of new pharmaceuticals is well known. Several comparable phased evaluation schemes have been proposed for medical tests. PURPOSE: To perform a systematic search of the literature, a synthesis, and a critical review of phased evaluation schemes for medical tests. DATA SOURCES: Literature databases of Medline, Web of Science, and Embase. STUDY SELECTION AND DATA EXTRACTION: Two authors separately evaluated potentially eligible papers and independently extracted data. RESULTS: We identified 19 schemes, published between 1978 and 2007. Despite their variability, these models show substantial similarity. Common phases are evaluations of technical efficacy, diagnostic accuracy, diagnostic thinking efficacy, therapeutic efficacy, patient outcome, and societal aspects. CONCLUSIONS: The evaluation frameworks can be useful to distinguish between study types, but they cannot be seen as a necessary sequence of evaluations. The evaluation of tests is most likely not a linear but a cyclic and repetitive process.

Various randomized designs can be used to evaluate medical tests.

OBJECTIVE: To explore designs for evaluating the prognostic and predictive value of medical tests and their effect on patient outcome. STUDY DESIGN: Theoretical analysis with examples from the medical literature. RESULTS: For evaluating the prognostic value of a test, one can include the test at baseline in prognostic studies. To evaluate the value of test in predicting treatment outcome, the test results can be used as baseline information in randomized controlled trials of treatment. To compare the prognostic or predictive value of two or more tests, the test result combinations can be used as baseline information. To evaluate the effect on patient outcome, randomized controlled trials of test strategies are an option. Randomization can apply to all tested or be restricted to specific subgroups, such as those with discordant test results, to increase the efficiency of trials. CONCLUSION: The prognostic and predictive value of medical tests can and should be evaluated, to demonstrate the test's ability to guide clinical decision making and to improve patient outcome. Various randomized designs can be used to evaluate the effects on testing on patient outcome.

Pharmacological treatment for unipolar psychotic depression: Systematic review and meta-analysis.

BACKGROUND: The optimal pharmacological treatment of unipolar psychotic depression is uncertain. AIMS: To compare the clinical effectiveness of pharmacological treatments for patients with unipolar psychotic depression. METHOD: Systematic review and meta-analysis of randomised controlled trials. RESULTS: Ten trials were included in the review. We found no evidence that the combination of an antidepressant with an antipsychotic is more effective than an antidepressant alone. This combination was statistically more effective than an antipsychotic alone. CONCLUSIONS: Antidepressant monotherapy and adding an antipsychotic if the patient does not respond, or starting with the combination of an antidepressant and an antipsychotic, both appear to be appropriate options for patients with unipolar psychotic depression. However, clinically the balance between risks and benefits may suggest the first option should be preferred for many patients. Starting with an antipsychotic alone appears to be inadequate.

Towards complete and accurate reporting of studies of diagnostic accuracy: the STARD initiative.

OBJECTIVE: Our aim was to improve the accuracy and completeness of reporting of studies of diagnostic accuracy in order to allow readers to assess the potential for bias in a study and to evaluate the generalizability of its results. METHODS: The Standards for Reporting of Diagnostic Accuracy (STARD) steering committee searched the literature to identify publications on the appropriate conduct and reporting of diagnostic studies and extracted potential items into an extensive list. Researchers, editors and members of professional organizations shortened this list during a 2-day consensus meeting with the goal of developing a checklist and a generic flow diagram for studies of diagnostic accuracy. RESULTS: The search for published guidelines about diagnostic research yielded 33 previously published checklists, from which we extracted a list of 75 potential items. At the consensus meeting, participants shortened the list to a 25-item checklist, by using evidence whenever available. A prototype of a flow diagram provides information about the method of recruitment of patients, the order of test execution and the numbers of patients undergoing the test under evaluation and/or the reference standard. CONCLUSIONS: Evaluation of research depends on complete and accurate reporting. If medical journals adopt the checklist and the flow diagram, the quality of reporting of studies of diagnostic accuracy should improve, to the advantage of clinicians, researchers, reviewers, journals and the public.

The diagnostic odds ratio: a single indicator of test performance.

Diagnostic testing can be used to discriminate subjects with a target disorder from subjects without it. Several indicators of diagnostic performance have been proposed, such as sensitivity and specificity. Using paired indicators can be a disadvantage in comparing the performance of competing tests, especially if one test does not outperform the other on both indicators. Here we propose the use of the odds ratio as a single indicator of diagnostic performance. The diagnostic odds ratio is closely linked to existing indicators, it facilitates formal meta-analysis of studies on diagnostic test performance, and it is derived from logistic models, which allow for the inclusion of additional variables to correct for heterogeneity. A disadvantage is the impossibility of weighing the true positive and false positive rate separately. In this article the application of the diagnostic odds ratio in test evaluation is illustrated.