University of Sheffield Medical School, Sheffield, UK.
Sheffield Teaching Hospitals NHS Foundation Trust, UK.
Int J Clin Pract. 2021 Apr;75(4):e13830. doi: 10.1111/ijcp.13830. Epub 2020 Nov 22.
Whilst core curricula in neurology are nationally standardised, in real-world clinical practice, different approaches may be taken by individual consultants. The aims of this study were to investigate differences by assessing: (a) variance in diagnostic and investigative practice, using a case-based analysis of inter-rater agreement; (b) potential importance of any differences in terms of patient care; (c) relationships between clinical experience, diagnostic certainty, diagnostic peer-agreement and investigative approach. The objective was to develop novel individualised metrics to facilitate reflection and appraisal.
Three neurologists with 6-23 years' experience at consultant level provided diagnosis, certainty (10-point Likert scale), and investigative approach for 200 consecutive general neurology outpatients seen by a newly qualified consultant in 2015. Diagnostic agreement was evaluated by percentage agreement. The potential importance of any diagnostic differences on patient outcome was assigned a score (6-point Likert scale) by the evaluating neurologist. Associations between diagnostic agreement, certainty and investigative approach were assessed using Spearman correlation, logistic and ordinal regression, and reported as individualised metrics for each rater.
Diagnostic peer-agreement was 3/3, 2/3 and 1/3 in 55.5%, 31.0% and 13.5% of cases, respectively. In 15.5%, differences in patient management were judged potentially important. Investigation rates were 42%-73%. Mean diagnostic certainty ranged from 6.63/10 (SD 1.98) to 7.72/10 (SD 2.20) between least and most experienced consultants. Greater diagnostic certainty was associated with greater diagnostic peer-agreement (individual-rater regression coefficients 0.33-0.44, P < .01) and lower odds of arranging investigations (individual-rater odds ratios 0.56-0.71, P < .01).
It appears that variance in diagnostic and investigative practice between consultant neurologists exists and may result in differing management. Mean diagnostic certainty was associated with greater diagnostic peer-agreement and lower investigation rates. Metrics reflecting concordance with peers, and relationships to diagnostic confidence, could be developed in larger cohorts to inform reflective practice.
虽然神经病学的核心课程在全国范围内是标准化的，但在实际临床实践中，不同的顾问可能会采取不同的方法。本研究旨在通过评估以下方面来调查差异：（a）使用基于案例的评分者间一致性分析，评估诊断和检查实践的差异；（b）从患者护理的角度评估任何差异的潜在重要性；（c）临床经验、诊断确定性、诊断评分者间一致性和检查方法之间的关系。目的是开发新的个体化指标，以促进反思和评估。
3 名具有 6-23 年顾问经验的神经病学家为 2015 年新聘顾问诊治的 200 名连续普通神经病学门诊患者提供诊断、确定性（10 分李克特量表）和检查方法。诊断一致性通过百分比一致性进行评估。评估神经病学家对任何诊断差异对患者结局的潜在重要性进行评分（6 分李克特量表）。使用 Spearman 相关、逻辑回归和有序回归评估诊断一致性、确定性和检查方法之间的关系，并作为每个评分者的个体化指标进行报告。
在 55.5%、31.0%和 13.5%的病例中，评分者间诊断一致性分别为 3/3、2/3 和 1/3。在 15.5%的病例中，认为患者管理的差异可能具有潜在重要性。检查率为 42%-73%。平均诊断确定性范围从经验最少的顾问的 6.63/10（标准差 1.98）到经验最多的顾问的 7.72/10（标准差 2.20）。较大的诊断确定性与更大的诊断评分者间一致性相关（个体评分者回归系数 0.33-0.44，P<.01），安排检查的可能性更低（个体评分者比值比 0.56-0.71，P<.01）。
似乎顾问神经病学家之间的诊断和检查实践存在差异，并且可能导致不同的治疗方法。平均诊断确定性与更大的诊断评分者间一致性和更低的检查率相关。反映与同行一致性的指标以及与诊断信心的关系，可以在更大的队列中开发，以提供反思实践的信息。
