Hand Peter J, Haisma Janneke A, Kwan Joseph, Lindley Richard I, Lamont Bart, Dennis Martin S, Wardlaw Joanna M
Division of Clinical Neurosciences, Western General Hospital, Edinburgh, UK.
Stroke. 2006 Mar;37(3):776-80. doi: 10.1161/01.STR.0000204042.41695.a1. Epub 2006 Feb 16.
Stroke remains primarily a clinical diagnosis, with information obtained from history and examination determining further management. We aimed to measure inter-rater reliability for the clinical assessment of stroke, with emphasis on items of history, timing of symptom onset, and diagnosis of stroke or mimic. We explored reasons for poor reliability.
The study was based in an urban hospital with an acute stroke unit. Pairs of observers independently assessed suspected stroke patients. Findings from history, neurological examination, and the diagnosis of stroke or mimic, were recorded on a standard form. Reliability was measured by the kappa statistic. We assessed the impact of observer experience and confidence, time of assessment, and patient-related factors of age, confusion, and aphasia on inter-rater reliability.
Ninety-eight patients were recruited. Most items of the history and the diagnosis of stroke were found to have moderate to good inter-rater reliability. There was agreement for the hour and minute of symptom onset in only 45% of cases. Observer experience and confidence improved reliability; patient-related factors of confusion and aphasia made the assessment more difficult. There was a trend for worse inter-rater reliability among patients assessed very early and very late after symptom onset.
Clinicians should be aware that inter-rater reliability of the clinical assessment is affected by a variety of factors and is improved by experience and confidence. Our findings have implications for training of doctors who assess patients with suspected stroke and identifies the more reliable components of the clinical assessment.
中风目前主要仍是临床诊断，通过病史和检查所获信息来决定后续治疗。我们旨在衡量中风临床评估中评估者间的可靠性，重点关注病史项目、症状发作时间以及中风或疑似中风的诊断。我们探究了可靠性差的原因。
该研究在一家设有急性中风单元的城市医院开展。成对的观察者独立评估疑似中风患者。病史、神经学检查结果以及中风或疑似中风的诊断均记录在一份标准表格上。可靠性通过kappa统计量进行衡量。我们评估了观察者经验与信心、评估时间以及患者相关因素（年龄、意识模糊和失语）对评估者间可靠性的影响。
招募了98名患者。发现病史的大多数项目以及中风的诊断具有中度到良好的评估者间可靠性。仅45%的病例在症状发作的小时和分钟上达成一致。观察者的经验和信心提高了可靠性；患者相关因素中的意识模糊和失语使评估更加困难。在症状发作后极早期和极晚期评估的患者中，评估者间可靠性有变差的趋势。
临床医生应意识到临床评估的评估者间可靠性受多种因素影响，且经验和信心可提高其可靠性。我们的研究结果对培训评估疑似中风患者的医生具有启示意义，并确定了临床评估中更可靠的组成部分。
