疑似肺栓塞患者前测概率评估的观察者间可靠性

The interobserver reliability of pretest probability assessment in patients with suspected pulmonary embolism.

作者信息

Rodger Marc A, Maser Elana, Stiell Ian, Howley Heather E A, Wells Philip S

机构信息

Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada.

出版信息

Thromb Res. 2005;116(2):101-7. doi: 10.1016/j.thromres.2004.10.011. Epub 2004 Nov 18.

DOI:10.1016/j.thromres.2004.10.011

PMID:15907523

Abstract

INTRODUCTION

Pretest probability assessment and objective testing are combined to appropriately manage patients with suspected pulmonary embolism (PE). However, the interobserver reliability of pretest probability assessment has not been investigated. We sought to determine (for patients with suspected PE) the interobserver reliability of pretest probability assessment (by overall impression (gestalt) versus an explicit clinical model).

MATERIALS AND METHODS

A prospective cohort study was conducted at an urban university hospital. For patients referred for ventilation and perfusion (V/Q) scanning for suspected PE, structured assessments (11 history and 4 physical examination parameters) were performed by a referring physician and a designated thrombosis physician. The referring and thrombosis physicians also assigned a pretest probability for PE (low, moderate, or high) by gestalt. An explicit seven-point clinical model for suspected PE was later applied to each structured assessment to determine the pretest probability. Assessments were performed independently and prior to diagnostic test results. Interobserver reliability (two rater unweighted Kappa (kappa) statistic) was determined for each parameter on the structured assessment and the pretest probability assessments (gestalt vs. explicit clinical model).

RESULTS

One hundred and ten patients with suspected PE received duplicate assessments. Historical features demonstrated substantial to almost perfect interobserver reliability (kappa=0.60-0.95). For the physical findings, only heart rate had substantial interobserver reliability (kappa=0.60). Pretest probability assessment was not reliable when using physician's gestalt (kappa=0.33), but produced substantial interobserver reliability using the explicit clinical model (kappa=0.62).

CONCLUSIONS

Given the inadequate interobserver reliability of pretest probability assessment by overall impression (or gestalt), physicians should use explicit clinical models in the diagnostic management of patients with suspected pulmonary embolism.

摘要

引言

将预测试概率评估与客观检测相结合，以恰当管理疑似肺栓塞（PE）的患者。然而，预测试概率评估的观察者间可靠性尚未得到研究。我们试图确定（针对疑似PE患者）预测试概率评估的观察者间可靠性（通过整体印象（格式塔）与明确的临床模型）。

材料与方法

在一家城市大学医院进行了一项前瞻性队列研究。对于因疑似PE而被转诊进行通气与灌注（V/Q）扫描的患者，由转诊医生和指定的血栓形成科医生进行结构化评估（11项病史和4项体格检查参数）。转诊医生和血栓形成科医生还通过整体印象为PE分配一个预测试概率（低、中或高）。随后将一个明确的七点疑似PE临床模型应用于每项结构化评估，以确定预测试概率。评估在诊断测试结果之前独立进行。确定了结构化评估中每个参数以及预测试概率评估（整体印象与明确临床模型）的观察者间可靠性（两位评估者的非加权Kappa（κ）统计量）。

结果

110例疑似PE患者接受了重复评估。病史特征显示观察者间可靠性从 substantial到几乎完美（κ = 0.60 - 0.95）。对于体格检查结果，只有心率具有 substantial观察者间可靠性（κ = 0.60）。使用医生的整体印象进行预测试概率评估不可靠（κ = 0.33），但使用明确的临床模型时观察者间可靠性为 substantial（κ = 0.62）。