Tobacman J K, Scott I U, Cyphert S, Zimmerman B
Department of Internal Medicine, University of Iowa, Iowa City, 52242-1081, USA.
Med Care. 1999 Sep;37(9):937-45. doi: 10.1097/00005650-199909000-00009.
Assess the reproducibility of methods to measure overuse of cataract surgery.
The objectives of this study are: (1) To determine the extent of agreement about clinical scenarios among, between, and within three physician panels; (2) to apply ratings of clinical scenarios from three panels to actual surgeries; and (3) to assess reproducibility of rates of appropriate use and overuse.
Three physician panels scored 2,894 clinical scenarios for the appropriate use of cataract surgery. One thousand and twenty charts were abstracted and assigned to the clinical scenario that best corresponded to the patient's clinical situation. Two hundred and fifty nine clinical scenarios were required to assign the cases. Weighted kappa values, confidence intervals, and percentages of agreement were used to measure agreement among, between, and within panels.
The all ophthalmologist panel (OP) and the convened multispecialty panel (CM) each rate 92% of the cases as appropriate use, compared with 70% by the mail-in multispecialty panel (MM). The MM have higher uncertain (26% vs. 8% and 7%) and higher inappropriate use (3.5% vs. 0.1% and 1.9%). For the clinical scenarios, the CM and the MM have similar percentages of overuse (6.6%, 7.3%), in contrast to the OP (0.4%). The weighted kappa value for the overall level of agreement about the clinical scenarios among the three panels is 0.53, consistent with moderate agreement.
Study results demonstrate reproducibility for assessment of appropriate use of surgery between the OP and CM. However, both multispecialty panels rate more clinical scenarios as inappropriate use than the ophthalmologist panel. Thus, reproducibility between the CM and the OP may be attributable to the low percentage of overuse of cataract surgery in the study population. The overall level of agreement about the clinical scenarios among the panels is moderate.
评估测量白内障手术过度使用情况方法的可重复性。
本研究的目的是：（1）确定三个医师小组之间、小组内部以及小组与小组之间对临床场景的一致程度；（2）将三个小组对临床场景的评分应用于实际手术；（3）评估合理使用和过度使用比率的可重复性。
三个医师小组对2894个白内障手术合理使用的临床场景进行评分。提取了1020份病历，并将其分配到与患者临床情况最相符的临床场景中。需要259个临床场景来分配病例。使用加权kappa值、置信区间和一致百分比来衡量小组之间、小组内部以及小组与小组之间的一致性。
所有眼科医生小组（OP）和召集的多专科小组（CM）将92%的病例评为合理使用，相比之下，邮寄多专科小组（MM）的这一比例为70%。MM小组有更高的不确定率（26%，而OP和CM小组分别为8%和7%）以及更高的不当使用率（3.5%，而OP和CM小组分别为0.1%和1.9%）。对于临床场景，CM小组和MM小组的过度使用率相似（分别为6.6%和7.3%），而OP小组为0.4%。三个小组之间关于临床场景总体一致程度的加权kappa值为0.53，符合中度一致。
研究结果表明，OP小组和CM小组在评估手术合理使用方面具有可重复性。然而，两个多专科小组将更多的临床场景评为不当使用，高于眼科医生小组。因此，CM小组和OP小组之间的可重复性可能归因于研究人群中白内障手术过度使用的比例较低。各小组之间关于临床场景的总体一致程度为中度。
