医生对心力衰竭术前诊断的意见一致与不一致的患者之间的差异。

Differences between patients in whom physicians agree versus disagree about the preoperative diagnosis of heart failure.

机构信息

Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, MI, USA.

Department of Internal Medicine, Division of Pulmonary and Critical Care, University of Michigan Medical School, Ann Arbor, MI, USA; Department of Computational Bioinformatics, University of Michigan Medical School, Ann Arbor, MI, USA.

出版信息

J Clin Anesth. 2023 Nov;90:111226. doi: 10.1016/j.jclinane.2023.111226. Epub 2023 Aug 5.

DOI:10.1016/j.jclinane.2023.111226

PMID:37549434

原文链接:https://pmc.ncbi.nlm.nih.gov/articles/PMC11221412/

Abstract

STUDY OBJECTIVE

To quantify preoperative heart failure (HF) diagnostic agreement and identify characteristics of patients in whom physicians agreed versus disagreed about the diagnosis.

DESIGN

Observational cohort study.

SETTING

Patients undergoing major non-cardiac surgery at an academic center between 2015 and 2019.

PATIENTS

40,659 patients undergoing major non-cardiac surgery, among which a stratified subsample of 1018 patients with and without documented HF was reviewed.

INTERVENTIONS

Via a panel of physicians frequently managing patients with HF (cardiologists, cardiac anesthesiologists, intensivists), detailed chart reviews were performed (two per patient; median review time 32 min per reviewer per patient) to render adjudicated HF diagnoses.

MEASUREMENTS

Adjudicated diagnostic agreement measures (percent agreement, Krippendorf's alpha) and univariate comparisons (standardized differences) between patients in whom physicians agreed versus disagreed about the preoperative HF diagnosis.

MAIN RESULTS

Among patients with documented HF, physicians agreed about the diagnosis in 80.0% of cases (consensus positive), disagreed in 13.8% (disagreement), and refuted the diagnosis in 6.3% (consensus negative). Conversely, among patients without documented HF, physicians agreed about the diagnosis in 88.0% (consensus negative), disagreed in 8.4% (disagreement), and refuted the diagnosis in 3.6% (consensus positive). The estimated agreement for the 40,659 cases was 91.1% (95% CI 88.3%-93.9%); Krippendorff's alpha was 0.77 (0.75-0.80). Compared to patients in whom physicians agreed about a HF diagnosis, patients in whom physicians disagreed exhibited fewer guideline-defined HF diagnostic criteria.

CONCLUSIONS

Physicians usually agree about HF diagnoses adjudicated via chart review, although disagreement is not uncommon and may be partly explained by heterogeneous clinical presentations. Our findings inform preoperative screening processes by identifying patients whose characteristics contribute to physician disagreement via chart review. Clinical Trial Number / Registry URL: Not applicable.

摘要

研究目的

量化术前心力衰竭（HF）的诊断一致性，并确定医生对诊断达成一致和不一致的患者特征。

设计

观察性队列研究。

地点

2015 年至 2019 年期间在学术中心接受非心脏大手术的患者。

患者

40659 例接受非心脏大手术的患者，其中回顾了 1018 例有和无记录的 HF 患者的分层亚样本。

干预措施

通过一组经常管理 HF 患者的医生（心脏病专家、心脏麻醉师、重症监护医生）进行详细的图表审查，以做出有裁决的 HF 诊断。

测量

有裁决的诊断一致性测量（百分比一致性、Krippendorff 的α）和医生对术前 HF 诊断达成一致和不一致的患者之间的单变量比较（标准化差异）。

主要结果

在有记录的 HF 患者中，医生在 80.0%的病例中对诊断达成一致（共识阳性），在 13.8%的病例中不同意（不一致），在 6.3%的病例中反驳诊断（共识阴性）。相反，在没有记录的 HF 患者中，医生在 88.0%的病例中对诊断达成一致（共识阴性），在 8.4%的病例中不同意（不一致），在 3.6%的病例中反驳诊断（共识阳性）。40659 例的估计一致性为 91.1%（95%置信区间 88.3%-93.9%）；Krippendorff 的α为 0.77（0.75-0.80）。与医生对 HF 诊断达成一致的患者相比，医生对 HF 诊断不一致的患者符合指南定义的 HF 诊断标准的较少。