Value-of-Information Analysis for External Validation of Risk Prediction Models in Multicenter Studies and Systematic Reviews

External validation studies have finite sample sizes, creating uncertainty about whether a prediction model's Net Benefit (NB) exceeds default strategies' NB.

The expected value of perfect information (EVPI) quantifies consequences of uncertainty.

Current EVPI methods focus on single studies, ignoring between-center heterogeneity.

We extend EVPI and expected value of partial perfect information (EVPPI) to account for between-cluster heterogeneity in multicenter studies and meta-analyses.

We distinguish between the global and local optimal strategy and between observed and unobserved clusters.

We define EVPIglobal, EVPIcluster_j, EVPIcluster, and EVPPIcluster,prevalence, implemented in the MetaNB R package, and illustrate them using a systematic review across 36 centers of the ADNEX model for ovarian cancer diagnosis.

Assuming one global decision regarding ADNEX adoption, there is no need for further data to confirm ADNEX is superior overall (EVPIglobal 0).

Meta-analysis borrows information across observed clusters, resulting in consistent local superiority of ADNEX and nonzero but typically lower EVPIcluster_j than when considering local data alone.

There is 0.03 probability default strategies are superior in unobserved centers.

Eliminating uncertainty on performance and prevalence in each (EVPIcluster) would gain 1134 net avoided false positives (FP) per year, assuming 350000 tumors annually with 20% malignancies.

Determining only local prevalence with certainty (EVPPIcluster, prevalence) would gain net 158 avoided FP per year.

EVPI extensions disentangle sources of uncertainty and quantify the need for further validation to determine the global or locally optimal strategy.

Considering uncertainty and heterogeneity in clinical utility across clusters is essential to decide whether additional validation studies are warranted.