Ordinal regression for meta-analysis of test accuracy: a flexible approach for utilising all threshold data

Abstract: Standard methods for meta-analysis and network-meta-analysis of test accuracy do not fully utilise available evidence, as they analyse thresholds separately, resulting in a loss of data unless every study reports all thresholds - which rarely occurs. Furthermore, previously proposed "multiple threshold" models introduce different problems: making overly restrictive assumptions, or failing to provide summary sensitivity and specificity estimates across thresholds. To address this, we proposed a series of ordinal regression-based models, representing a natural extension of established frameworks. Our approach offers notable advantages: (i) complete data utilisation: rather than discarding information like standard methods, we incorporate all threshold data; (ii) threshold-specific inference: by providing summary accuracy estimates across thresholds, our models deliver critical information for clinical decision-making; (iii) enhanced flexibility: unlike previous "multiple thresholds" approaches, our methodology imposes fewer assumptions, leading to better accuracy estimates; (iv) our models use an induced-Dirichlet framework, allowing for either fixed-effects or random-effects cutpoint parameters, whilst also allowing for intuitive cutpoint priors. Our (ongoing) simulation study - based on real-world anxiety and depression screening data - demonstrates notably better accuracy estimates than previous approaches, even when the number of categories is high. Furthermore, we implemented these models in a user-friendly R package - MetaOrdDTA (https://github.com/CerulloE1996/MetaOrdDTA). The package uses Stan and produces MCMC summaries, sROC plots with credible/prediction regions, and meta-regression. Overall, our approach establishes a more comprehensive framework for synthesising test accuracy data, better serving systematic reviewers and clinical decision-makers.