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.
J Clin Anesth. 2023 Nov;90:111226. doi: 10.1016/j.jclinane.2023.111226. Epub 2023 Aug 5.
To quantify preoperative heart failure (HF) diagnostic agreement and identify characteristics of patients in whom physicians agreed versus disagreed about the diagnosis.
Observational cohort study.
Patients undergoing major non-cardiac surgery at an academic center between 2015 and 2019.
40,659 patients undergoing major non-cardiac surgery, among which a stratified subsample of 1018 patients with and without documented HF was reviewed.
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.
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.
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.
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.
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。
观察性队列研究。
2015 年至 2019 年期间在学术中心接受非心脏大手术的患者。
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。
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。
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）。
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。
尽管医生对 HF 诊断的意见不一致并不少见，并且可能部分解释为临床表现的异质性，但通过图表审查，医生通常对 HF 诊断达成一致。我们的研究结果通过识别那些通过图表审查导致医生意见不一致的患者特征，为术前筛查过程提供了信息。
临床试验编号/注册网址：不适用。
