Kidwell 2000.

Study characteristics
Patient sampling	UCLA Medical Center, USA Sampling: prospective but not consecutive as the paramedics completed LAPSS forms on 206/446 people with neurologically relevant symptoms (analysis based on all runs, including those without completed forms, also reported but not included in the review).
Patient characteristics and setting	Inclusion and exclusion criteria: sole inclusion criterion was transport by a paramedic vehicle involved in the study during the enrolment period. Target stroke population was non‐comatose, non‐trauma people with symptom duration < 24 hours with suspected ischemic stroke, ICH or TIA if person was still symptomatic at the time of initial paramedic examination. 2‐stage LAPSS screening process: stage 1: paramedics were asked to identify all non‐comatose, non‐trauma people having neurologic complaints, i.e. people with potential stroke or stroke mimic: altered LOC, local neurologic signs, seizure, syncope, head pain, and cluster category of weak/dizzy/sick. Examples of categories that were not neurologically relevant included chest pain, allergic reaction, abdominal pain, and shortness of breath; stage 2: criteria for LAPSS form completion were: age ≥ 18 years, neurologically relevant complaint, absence of coma, and non‐traumatic presentation. Participant characteristics: mean age 67 years; 52% men
Index tests	Index test: LAPSS Test administrator: paramedics Training: a brief certification tape was used that consisted of 5 video vignettes of paramedics performing the LAPSS examination on 3 people with stroke, 1 stroke mimic (alcohol intoxication) and 1 healthy person. After the LAPSS‐based education session, trainees watched the certification tape and completed the LAPSS exam on each vignette. Certification for use of the LAPSS required correct completion of the LAPSS exam on all 5 people. If certification was not achieved on the first trial, paramedics underwent further education in a small group setting focused on typical exam errors and then repeated the certification exam until all 5 people were correctly identified. To both reinforce and determine the impact of the training sessions, a 19‐item stroke knowledge test was administered before and after the education session. The test included 8 items regarding stroke symptoms and diagnosis, 7 questions regarding acute stroke care and 4 items regarding stroke pathophysiology.
Target condition and reference standard(s)	Target condition: stroke/TIA Reference standard: for all runs, 1 blinded author (KW) reviewed ER charts, recorded final ER discharge diagnoses and confirmed absence or presence of potential stroke symptoms. On all potential target stroke runs (people meeting LAPSS form completion criteria), 1 blinded author (CSK) additionally examined all inpatient medical records to confirm hospital discharge diagnoses of ischemic stroke, ICH and TIA by review of reports from imaging studies and attending physician notes. For people with the diagnosis of TIA, a consensus on final diagnosis was reached after complete medical record review and case discussion with a second stroke neurologist. In all people with cerebral infarct and ICH, the diagnosis of the blinded reviewer agreed with the charted diagnosis of the attending neurologist.
Flow and timing	446 people had neurologically relevant symptoms, of these paramedics applied LAPSS on 206.
Comparative
Diagnostic test accuracy data	Prevalence of stroke/TIA: 34/206 (16.5%) LAPSS: TP = 31; FP = 5; FN = 3; TN = 167
Notes	Categorization of alternate diagnosis for participants who did not have an ischemic stroke: not reported Funding: Grant‐in‐aid from the American Heart Association, Greater Los Angeles Affiliate
Methodological quality
Item	Authors' judgement	Risk of bias	Applicability concerns
DOMAIN 1: Patient Selection
Was a consecutive or random sample of patients enrolled?	No
Was a case‐control design avoided?	Yes
Did the study avoid inappropriate exclusions?	Yes
Prospective design	Yes
		High	Low
DOMAIN 2: Index Test Index tests
Were the index test results interpreted without knowledge of the results of the reference standard?	Yes
If a threshold was used, was it pre‐specified?	Yes
		Low	Low
DOMAIN 3: Reference Standard
Is the reference standards likely to correctly classify the target condition?	Yes
Were the reference standard results interpreted without knowledge of the results of the index tests?	Yes
		Low	Low
DOMAIN 4: Flow and Timing
Was there an appropriate interval between index test and reference standard?	Yes
Did all patients receive the same reference standard?	Unclear
Were all patients included in the analysis?	Yes
Did all patients receive a reference standard?	Yes
		Unclear