Objective To compare the diagnostic accuracy of the IOTA Simple Rules for classifying adnexal masses when applied by expert versus nonexpert ultrasound operators, and to assess whether diagnostic performance is maintained across different levels of examiner experience.Methods A systematic review and meta-analysis was performed according to PRISMA-DTA guidelines. PubMed, Scopus, and Embase were searched for studies evaluating the IOTA Simple Rules with histopathology as the reference standard. Studies were stratified by operator experience: experts (IOTA-trained subspecialists) and nonexperts (general gynecologists or trainees). Pooled sensitivity, specificity, likelihood ratios, diagnostic odds ratios, and HSROC curves were calculated using a bivariate random-effects model. Heterogeneity was quantified using I2 and Q statistics, and publication bias was assessed.Results Thirty studies (25 with expert and 11 with nonexpert examiners) were included, encompassing adnexal masses with a mean malignancy prevalence of 27%. Among expert operators, pooled sensitivity and specificity were 0.90 (95% CI 0.86-0.92) and 0.93 (95% CI 0.91-0.95), respectively, with an AUC of 0.96. Among nonexpert operators, pooled sensitivity and specificity were 0.88 (95% CI 0.82-0.92) and 0.92 (95% CI 0.86-0.96), with an AUC of 0.95. Diagnostic odds ratios were 118 for experts and 86 for nonexperts. Differences in accuracy between groups were nonstatistically significant and, therefore, clinically negligible. Using an estimated prevalence of 27%, the positive posttest probability was 84% for experts and 81% for nonexperts, while the negative posttest probability was 4% and 5%, respectively. No significant publication bias was detected.Conclusion The IOTA Simple Rules demonstrate excellent diagnostic accuracy when used by both expert and nonexpert operators, with only minor differences in performance. These findings confirm that the Simple Rules are reproducible, robust and transferable across different clinical experience levels, supporting their role as an accessible and reliable triage tool for adnexal mass assessment, including outside tertiary referral centers.
Have Iota Simple Rules the Same Diagnostic Performance When Used by Nonexpert Examiners as Compared to Expert Examiners? Systematic Review and Meta-Analisis
Guerriero S.;
2026-01-01
Abstract
Objective To compare the diagnostic accuracy of the IOTA Simple Rules for classifying adnexal masses when applied by expert versus nonexpert ultrasound operators, and to assess whether diagnostic performance is maintained across different levels of examiner experience.Methods A systematic review and meta-analysis was performed according to PRISMA-DTA guidelines. PubMed, Scopus, and Embase were searched for studies evaluating the IOTA Simple Rules with histopathology as the reference standard. Studies were stratified by operator experience: experts (IOTA-trained subspecialists) and nonexperts (general gynecologists or trainees). Pooled sensitivity, specificity, likelihood ratios, diagnostic odds ratios, and HSROC curves were calculated using a bivariate random-effects model. Heterogeneity was quantified using I2 and Q statistics, and publication bias was assessed.Results Thirty studies (25 with expert and 11 with nonexpert examiners) were included, encompassing adnexal masses with a mean malignancy prevalence of 27%. Among expert operators, pooled sensitivity and specificity were 0.90 (95% CI 0.86-0.92) and 0.93 (95% CI 0.91-0.95), respectively, with an AUC of 0.96. Among nonexpert operators, pooled sensitivity and specificity were 0.88 (95% CI 0.82-0.92) and 0.92 (95% CI 0.86-0.96), with an AUC of 0.95. Diagnostic odds ratios were 118 for experts and 86 for nonexperts. Differences in accuracy between groups were nonstatistically significant and, therefore, clinically negligible. Using an estimated prevalence of 27%, the positive posttest probability was 84% for experts and 81% for nonexperts, while the negative posttest probability was 4% and 5%, respectively. No significant publication bias was detected.Conclusion The IOTA Simple Rules demonstrate excellent diagnostic accuracy when used by both expert and nonexpert operators, with only minor differences in performance. These findings confirm that the Simple Rules are reproducible, robust and transferable across different clinical experience levels, supporting their role as an accessible and reliable triage tool for adnexal mass assessment, including outside tertiary referral centers.
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