Department of Orthopaedics and Rehabilitation, Yale University School of Medicine, 800 Howard Avenue, New Haven, CT 06510, USA.
Department of Pediatrics, Yale University School of Medicine, P.O. Box 208064, 333 Cedar Street, New Haven, CT 06520-8064, USA.
Child Abuse Negl. 2017 Oct;72:140-146. doi: 10.1016/j.chiabu.2017.08.001. Epub 2017 Aug 10.
As there is no "gold standard" in determining whether a fracture is caused by accident or abuse, agreement among medical providers is paramount. Using abstracted medical record data from 551 children <36months of age presenting to a pediatric emergency department, we examined the extent of agreement between specialists who evaluate children with fractures for suspected abuse. To simulate clinical scenarios, two pediatric orthopaedists and two child abuse pediatricians (CAPs) reviewed the full abstraction and imaging, whereas the two pediatric radiologists reviewed a brief history and imaging. Each physician independently rated each case using a 7-point ordinal scale designed to distinguish accidental from abusive injuries. For any discrepancy in independent ratings, the two specialists discussed the case and came to a joint rating. We analyzed 3 types of agreement: (1) within specialties using independent ratings, (2) between specialties using joint ratings, and (3) between clinicians (orthopaedists and CAPs) with more versus less experience. Agreement between pairs of raters was assessed using Cohen's weighted kappa. Orthopaedists (κ=0.78) and CAPs (κ=0.67) had substantial within-specialty agreement, while radiologists (κ=0.53) had moderate agreement. Orthopaedists and CAPs had almost perfect between-specialty agreement (κ=0.81), while agreement was much lower for orthopaedists and radiologists (κ=0.37) and CAPs and radiologists (κ=0.42). More-experienced clinicians had substantial between-specialty agreement (κ=0.80) versus less-experienced clinicians who had moderate agreement (κ=0.60). These findings suggest the level of clinical detail a physician receives and his/her experience in the field has an impact on the level of agreement when evaluating fractures in young children.
由于没有“金标准”来确定骨折是意外还是虐待造成的，因此医疗提供者之间的共识至关重要。我们使用从儿科急诊室就诊的 551 名<36 个月龄的儿童的病历数据摘要，检查了评估疑似虐待儿童骨折的专家之间的一致性程度。为了模拟临床情况，两位儿科骨科医生和两位儿童虐待儿科医生（CAP）查看了完整的摘要和影像学结果，而两位儿科放射科医生则查看了简短的病史和影像学结果。每位医生都使用 7 分制的等级量表独立评估每个病例，该量表旨在区分意外和虐待性损伤。对于独立评分的任何差异，两位专家都会讨论病例并得出联合评分。我们分析了 3 种类型的一致性：（1）使用独立评分的专业内一致性，（2）使用联合评分的专业间一致性，以及（3）经验更多与经验较少的临床医生（骨科医生和 CAP）之间的一致性。使用 Cohen 的加权 kappa 评估评分者之间的一致性。骨科医生（κ=0.78）和 CAP（κ=0.67）在专业内具有实质性的一致性，而放射科医生（κ=0.53）具有中度一致性。骨科医生和 CAP 之间具有近乎完美的专业间一致性（κ=0.81），而骨科医生和放射科医生（κ=0.37）和 CAP 和放射科医生（κ=0.42）之间的一致性要低得多。经验丰富的临床医生在专业间具有实质性的一致性（κ=0.80），而经验较少的临床医生具有中度一致性（κ=0.60）。这些发现表明，医生接受的临床细节水平及其在该领域的经验会影响评估幼儿骨折时的一致性水平。
