Table 1

Application of the checklist

Liu et al67 analysed 82 studies published between January 2012 and June 2019 which compared diagnostic performance of deep learning algorithms and healthcare professionals based on medical imaging for 17 different clinical conditions. The authors extracted diagnostic accuracy data and constructed contingency tables to derive the measures of interest. In generating responses to each item on the checklist, we used information stated in the review or, if certain information was missing, retrieved from the individual full-text articles.
1. What is the purpose of the algorithm?Objective and context of the algorithms were adequately stated in included studies.
2a. How good were the data used to train the algorithm? 2b. To what extent were the data accurate and free of bias? 2c. Were the data standardised and interoperable?26 studies (32%) did not report patient inclusion criteria; 33 studies (40%) did not report exclusion criteria; 30 studies (37%) did not report age and 43 studies (52%) did not report sex. 72 studies (88%) used retrospectively collected data from historical routine care (48 studies) or open source (24 studies) registries which are rarely quality controlled for images or accompanying labels, and in which population characteristics are either not collected or inaccessible; only 10 studies (12%) used prospectively collected data specific to a research setting. 26 studies (32%) excluded low-quality images; 18 (22%) retained low-quality images; 38 (46%) did not report this. The extent of missing data, and how this was handled, was poorly reported in all studies. All data used in 36 studies (44%) were obtained at a single hospital or medical centre. The extent to which data were standardised and rendered interoperable across sites in multisite studies was not reported in any study.
3. Were there sufficient data to train the algorithm?57 studies (69%) did not report the number of participants represented by the training data; in remaining studies, the numbers ranged from 40 to 200 000. No study pre-specified a sample size.
4. How well does the algorithm perform?For internal validation, 22 studies (27%) used resampling methods, 29 studies (35%) used random split sampling, 1 study (1%) used stratified random sampling, and 30 studies (37%) did not report any form of internal validation. 69 studies (84%) provided adequate data to construct contingency tables. In these studies sensitivity ranged from 9.7% to 100.0% (mean±SD 79.1%±0.2%); specificity ranged from 38.9% to 100.0% (mean±SD 88.3%±0.1%). Only 12 studies (14.6%) reported cut-points for determining sensitivity and specificity for which no justification was provided. The same reference standard was used across internal validation datasets in 61 studies (74%). Reference standards varied widely according to target condition and imaging modality. More rigorous expert group consensus standards were used in 66 studies (80%); remaining studies relied on single expert consensus (n=1), existing clinical care notes or imaging reports or existing labels (n=11), clinical follow-up (n=9), surgical confirmation (n=2), another imaging modality (n=1) and laboratory testing (n=3). No comments were made about outlier studies although AUROC curves depicted within the review clearly indicated there were such studies. Only 25 of 82 studies (36%) performed external validation. In these studies, the pooled sensitivity was 88.6% (95% CI 85.7 to 90.9) and pooled specificity was 93.9% (95% CI 92.2 to 95.3). Studies were inconsistent in their use of the term ‘validation’ as it applied to testing datasets; there was often lack of transparency as to whether testing sets were truly independent of training sets.
5. Is the algorithm transferable to new clinical settings?Only 9 studies (11%) assessed algorithm performance in real-world contexts where clinicians received additional clinical information alongside the image, rather than just view the image in isolation.
6. Are the outputs of the algorithm clinically intelligible?81 studies (99%) used artificial or convoluted neural networks; 1 study did not report algorithm architecture. Only 32 studies (39%) provided a heat map of salient features.
7. How will this algorithm fit into and complement current workflows?No studies reported how their algorithms impacted real-world clinical workflows. In one study which compared algorithm performance among pathologists simulating normal workflows (ie, imposed time constraints) with that of a single pathologist with no time constraint, the AUROC were the same (0.96).*
8. Has use of the algorithm been shown to improve patient care and outcomes?None of the algorithms in these studies have been subjected to clinical trials aimed at demonstrating improved care or patient outcomes.
9. Could the algorithm cause patient harm?No comments were made about potential harms.
10. Does use of the algorithm raise ethical, legal or social concerns?No comments were made about any such concerns.
  • *Bhteshami Bejnordi BE, Veta M, van Diest PJ, et al. Diagnostic assessment of deep learning algorithms for detection of lymph node metastases in women with breast cancer. JAMA 2017;318(22):2199–2210.

  • AUROC, area under receiving operator characteristic curve.