Nordenholz Kristen E, Naviaux N Ward, Stegelmeier Krynn, Haukoos Jason S, Wolf Stephen J, McCubbin Tracy, Heard Kennon
Division of Emergency Medicine, Department of Surgery, University of Colorado School of Medicine, Denver, CO 80262, USA.
Am J Emerg Med. 2007 Mar;25(3):285-90. doi: 10.1016/j.ajem.2006.08.016.
Diagnostic evaluation for suspected pulmonary embolism (PE) is challenging. Dimerized plasmin fragment D (D-dimer) assays are increasingly used but have been validated only in "low-risk" patients. The accurate interpretation and application of risk assessment criteria are critical to the appropriate use of D-dimer. We sought to determine the interrater agreement of attending and third-year resident emergency medicine physicians in the specific elements of the Canadian and the Charlotte risk stratification tools and their clinical application.
We prospectively enrolled a convenience sample of patients presenting to an urban university emergency department with suspected PE. Standardized data collection sheets were used by an attending physician and a third-year resident physician to determine the presence or absence of risk factors included in published PE prediction instruments. Each physician was blinded to the other's results and the patients' D-dimer result. Interrater agreement was measured using kappa statistics (with 95% confidence intervals).
Two hundred seventy-one patients were screened. The kappa scores for each risk criterion were as follows: previous deep vein thrombosis, 0.90 (95% confidence interval, 0.83-0.97); malignancy, 0.87 (0.76-0.97); deep vein thrombosis symptoms, 0.54 (0.39-0.70); immobilization, 0.41 (0.26-0.57); unexplained hypoxia, 0.58 (0.42-0.74); tachycardia, 0.94 (0.89-0.98); hemoptysis, 0.76 (0.51-1.0); and PE more likely than another diagnosis, 0.50 (0.36-0.64).
Interrater agreement was only fair for several important risk criteria. Small differences in determining pretest probability can lead to significant variability in risk assessment and how, or whether, the diagnosis of PE is evaluated. This study raises questions about the reliability and applicability of published PE screening criteria in clinical settings.
对疑似肺栓塞（PE）的诊断评估具有挑战性。二聚体化纤溶酶片段D（D-二聚体）检测的应用越来越广泛，但仅在“低风险”患者中得到验证。准确解读和应用风险评估标准对于D-二聚体的合理使用至关重要。我们试图确定主治医生和三年级住院急诊医学医生在加拿大和夏洛特风险分层工具的具体要素及其临床应用方面的评分者间一致性。
我们前瞻性地纳入了一个方便样本，即到一所城市大学急诊科就诊且疑似患有PE的患者。主治医生和三年级住院医生使用标准化数据收集表来确定已发表的PE预测工具中所包含的风险因素的有无。每位医生对对方的结果和患者的D-二聚体结果均不知情。使用kappa统计量（95%置信区间）来测量评分者间一致性。
共筛查了271名患者。每个风险标准的kappa评分如下：既往深静脉血栓形成，0.90（95%置信区间，0.83 - 0.97）；恶性肿瘤，0.87（0.76 - 0.97）；深静脉血栓形成症状，0.54（0.39 - 0.70）；制动，0.41（0.26 - 0.57）；不明原因的低氧血症，0.58（0.42 - 0.74）；心动过速，0.94（0.89 - 0.98）；咯血，0.76（0.51 - 1.0）；PE比其他诊断更有可能，0.50（0.36 - 0.64）。
对于几个重要的风险标准，评分者间一致性仅为中等。在确定验前概率方面的微小差异可能导致风险评估以及对PE诊断的评估方式（或是否进行评估）出现显著差异。本研究对已发表的PE筛查标准在临床环境中的可靠性和适用性提出了质疑。
