急诊脑卒中识别量表诊断准确性的Meta分析

Diagnostic accuracy of recognition of stroke in the emergency room scale:a Meta-analysis

目的利用系统综述和Meta分析方法全面评价急诊脑卒中识别量表(ROSIER)的诊断准确性和临床适用性。方法全面系统检索2005年1月1日至2018年12月31日在美国国立医学图书馆PubMed数据库、荷兰医学文摘Embase数据库、万方数据库、维普数据库(VIP)和中国知网数据库(CNKI)发表的涉及ROSIER诊断准确性的中英文文献。ROSIER诊断的敏感度、特异度和诊断比值比(DOR)采用双变量混合效应模型合并,并进行亚组分析;采用敏感性分析方法对研究结果的稳定性进行评价;采用Deek漏斗图评价文献发表偏倚;采用范根图评价ROSIER的临床适用性。结果共28项研究涵盖7 579例研究对象纳入分析。总体Meta分析显示,ROSIER合并的敏感度、特异度和DOR分别为0.89〔95%可信区间(95%CI)=0.86~0.91,P=0.00〕、0.74(95%CI=0.67~0.80,P=0.00)和22.09(95%CI=14.86~32.82,P=0.00)。ROSIER合并敏感度的亚组分析结果显示,亚洲人群明显高于欧洲人群〔0.89(95%CI=0.86~0.92)比0.74(95%CI=0.66~0.82),P<0.01〕,前瞻性研究明显高于回顾性研究〔0.89(95%CI=0.87~0.92)比0.74(95%CI=0.61~0.88),P<0.05〕,院前急救明显高于急救中心〔0.87(95%CI=0.80~0.94)比0.85(95%CI=0.81~0.90),P<0.01〕,样本量≤200例的研究明显高于样本量>200例的研究〔0.88(95%CI=0.83~0.93)比0.82(95%CI=0.76~0.88),P<0.05〕;而不同评价人员和不同男女比例亚组间比较差异无统计学意义。ROSIER合并特异度的亚组分析显示,欧洲人群明显高于亚洲人群〔0.81(95%CI=0.73~0.89)比0.79(95%CI=0.73~0.85),P<0.05〕,回顾性研究明显高于前瞻性研究〔0.88(95%CI=0.78~0.97)比0.79(95%CI=0.73~0.84),P<0.05〕,院前急救明显高于急救中心〔0.82(95%CI=0.73~0.91)比0.79(95%CI=0.73~0.85),P<0.01〕,急诊医师明显高于其他人员〔0.80(95%CI=0.74~0.86)比0.79(95%CI=0.69~0.90),P<0.05〕,样本量≤200例的研究明显高于样本量>200例的研究〔0.82(95%CI=0.76~0.89)比0.78(95%CI=0.71~0.85),P<0.05〕;而不同男女比例亚组间比较差异无统计学意义。敏感性分析显示,逐篇剔除每项研究前后合并DOR未发生显著变化,说明研究结果较为稳定。漏斗图显示,总体研究存在显著发表偏倚(P=0.04),但欧洲人群(P=0.57)和亚洲人群(P=0.08)研究均不存在发表偏倚。范根图显示,预设验前概率为50%,当ROSIER诊断阳性时,受试者被诊断为脑卒中的概率上升至77%;当ROSIER诊断阴性时,受试者被诊断为非脑卒中的概率下降至13%。提示ROSIER的适用性较好,具有较高的临床诊断价值。结论ROSIER对脑卒中具有较高的诊断价值,且敏感度、特异度均较高,是一项临床适用性较好的脑卒中识别量表,可广泛应用于亚洲人群、院前急救和经过系统培训的医务工作者。

Objective To systematically evaluate the diagnostic accuracy and clinical applicability of recognition of stroke in the emergency room(ROSIER)scale by systematic review and Meta-analysis.Methods The Chinese and English literatures concerning the diagnostic accuracy of ROSIER published from January 1st 2005 to December 31st 2018 by PubMed,Embase,Wanfang,VIP and CNKI databases were searched comprehensively and systematically.The sensitivity,specificity,and diagnostic odds ratio(DOR)of ROSIER in total population and subgroup analysis were pooled by using bivariate mixed effects model.Sensitivity analysis was used to evaluate the stability of the results.Deek funnel plot was utilized to evaluate publication bias.The clinical applicability of ROSIER was evaluated by Fagan Nomogram.Results A total of 28 studies incorporating 7 579 subjects were enrolled in this Meta-analysis.Meta-analysis in total population showed that the pooled sensitivity,specificity and DOR of ROSIER was 0.89[95%confidence interval(95%CI)=0.86-0.91,P=0.00],0.74(95%CI=0.67-0.80,P=0.00)and 22.09(95%CI=14.86-32.82,P=0.00),respectively.Subgroup analysis of pooled sensitivity of ROSIER showed that Asian patients was significantly higher than European patients[0.89(95%CI=0.86-0.92)vs.0.74(95%CI=0.66-0.82),P<0.01],prospective study was significantly higher than retrospective study[0.89(95%CI=0.87-0.92)vs.0.74(95%CI=0.61-0.88),P<0.05],pre-hospital emergency was significantly higher than emergency department[0.87(95%CI=0.80-0.94)vs.0.85(95%CI=0.81-0.90),P<0.01],study with sample size≤200 was significantly higher than study with sample size>200[0.88(95%CI=0.83-0.93)vs.0.82(95%CI=0.76-0.88),P<0.05],but there was no significant difference between different evaluators or different male to female ratio subgroups.Subgroup analysis of pooled specificity of ROSIER showed that European patients was significantly higher than Asian patients[0.81(95%CI=0.73-0.89)vs.0.79(95%CI=0.73-0.85),P<0.05],retrospective study was significantly higher than prospective study[0.88(95%CI=0.78-0.97)vs.0.79(95%CI=0.73-0.84),P<0.05],pre-hospital emergency was significantly higher than emergency department[0.82(95%CI=0.73-0.91)vs.0.79(95%CI=0.73-0.85),P<0.01],emergency physicians was significantly higher than other medical workers[0.80(95%CI=0.74-0.86)vs.0.79(95%CI=0.69-0.90),P<0.05],study with sample size≤200 was significantly higher than study with sample size>200[0.82(95%CI=0.76-0.89)vs.0.78(95%CI=0.71-0.85),P<0.05],but there was no significant difference between different male or female ratio subgroups.Sensitivity analysis showed that there was no significant change in pooled DOR before and after excluding each study,indicating that the results were stable.Funnel plot showed that there was a significant publication bias in the total population(P=0.04),but there was no publication bias in the European population(P=0.57)or the Asian population(P=0.08).According to the results of the Fagan Nomogram,with the pretest probability of 50%,when ROSIER was positive,the probability of being diagnosed with stroke increased to 77%,and when ROSIER was negative,the probability of being diagnosed with non-stroke decreased to 13%.It was suggested that ROSIER had good applicability and high clinical diagnostic value.Conclusions ROSIER has high diagnostic sensitivity and specificity,and has high clinical diagnostic value.It is a valid stroke identification tool which can be widely used in Asian population,pre-hospital emergency and be utilized by trained medical worker.