OBJECTIVE:Evaluations of screening or diagnostic tests sometimes incorporate measures of overall accuracy , diagnostic accuracy , or test efficiency . These terms refer to a single summary measurement calculated from 2 × × × × 2 contingency tables that is the overall probability that a patient will be correctly classified by a screening or diagnostic test. We assessed the value of overall accuracy in studies of test validity, a topic that has not received adequate emphasis in the clinical literature. DESIGN:Guided by previous reports, we summarize the issues concerning the use of overall accuracy. To document its use in contemporary studies, a search was performed for test evaluation studies published in the clinical literature from 2000 to 2002 in which overall accuracy derived from a 2 × × × × 2 contingency table was reported. MEASUREMENTS AND MAIN RESULTS:Overall accuracy is the weighted average of a test's sensitivity and specificity, where sensitivity is weighted by prevalence and specificity is weighted by the complement of prevalence. Overall accuracy becomes particularly problematic as a measure of validity as 1) the difference between sensitivity and specificity increases and/or 2) the prevalence deviates away from 50%. Both situations lead to an increasing deviation between overall accuracy and either sensitivity or specificity. A summary of results from published studies ( N = = = = 25) illustrated that the prevalencedependent nature of overall accuracy has potentially negative consequences that can lead to a distorted impression of the validity of a screening or diagnostic test. CONCLUSIONS:Despite the intuitive appeal of overall accuracy as a single measure of test validity, its dependence on prevalence renders it inferior to the careful and balanced consideration of sensitivity and specificity.

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This column describes Project ECHO (Extension for Community Healthcare Outcomes), a teleconsultation, tele-education, telementoring model for enhancing primary care treatment of underserved patients with complex medical conditions. Numerous centers have adapted ECHO to support primary care treatment of behavioral health disorders. Preliminary evidence for behavioral health ECHO programs suggests positive impacts on providers, treatment planning, and emergency department costs. ECHO has the potential to improve access to effective and cost-effective behavioral health care by virtually integrating behavioral health knowledge and support in sites where specialty providers are not available. Patient-level outcomes research is critical.

Rural communities disproportionately experience behavioral health care shortages. This study examines outcomes among the patients of rural primary care teams trained and supported to deliver behavioral health care. Patients (n ϭ 243) completed 5 iterations of the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5) Self-Rated Level 1 Cross-Cutting Symptom Measures (American Psychiatric Association, 2013) and the World Health Organization Disability Assessment Schedule 2.0 (World Health Organization, 2012). Survey data were used in multiple linear regressions to assess health changes. Patients who received treatment from teams experienced less anxiety, sleep problems, and cognition problems over time. This exploratory research shows supporting primary care teams to deliver behavioral health care is associated with improved behavioral health and functioning among rural patient populations.

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97 out of 233 patients (= 41.6%) displayed persistent tardive dyskinesia. In univariate analysis, significant associations were found between tardive dyskinesia and the following independent variables (higher values means greater risk): Age (p = 0.0001), years from onset of the disorder (p = 0.001), total length of stay in hospital (p = 0.001), PANSS (single scales and sum score) (p = 0.0001), total amount of neuroleptics expressed as CPZ equivalents (p = 0.004). Logistic regression analysis showed that only the variables "age" and "negative symptoms" expressed as score on the PANSS negative subscale showed an association with tardive dyskinesia that could not be explained by covariation with other variables. The same results were found when, instead of the dichotomous variable "tardive dyskinesia yes/no" the associations with the TDRS score were analyzed. Future research should aim to approach the neurobiological correlates of "age" and "negative symptoms" in relationship to tardive dyskinesia.