Gordon D L, Bendixen B H, Adams H P, Clarke W, Kappelle L J, Woolson R F
Department of Neurology, University of Iowa College of Medicine, Iowa City.
Neurology. 1993 May;43(5):1021-7. doi: 10.1212/wnl.43.5.1021.
To test interphysician agreement on the diagnosis of subtype of ischemic stroke, we sent subtype definitions and 18 case summaries (clinical features and pertinent laboratory data) to 24 neurologists who have a special interest in stroke, and asked them to determine the most likely subtype diagnosis. The overall agreement was 0.64 (Kappa [K] = 0.54). Interphysician agreement was highest for the diagnoses of stroke secondary to cardioembolism (K = 0.75) or to large-artery atherosclerosis (K = 0.69). Individual physicians varied widely; four agreed with the consensus diagnosis in all 18 cases, while six others disagreed with the consensus diagnosis in three to five cases. Our level of interphysician agreement is greater than that reported in other studies and was substantial. However, despite using subtype definitions and being given extensive information often not available in the acute setting, physicians still disagree about the etiology of stroke, particularly in regard to stroke due to small-artery occlusion or of undetermined etiology. Physicians seem reluctant not to attribute stroke to a specific etiology. The uncertainty about subtype diagnosis will affect interpretation of the results of clinical trials in patients selected by the subtype of ischemic stroke and also suggests that results of treatment as affected by subtype should be cautiously interpreted unless efforts to assure uniformity are included in the trial's operations. Refinement of algorithms for determining subtype of ischemic stroke do improve interphysician agreement. Such criteria should be applied strictly, and trials should include measures to assure the most uniform diagnosis of stroke subtype possible.
为了测试医生之间对缺血性中风亚型诊断的一致性，我们将亚型定义和18份病例摘要（临床特征和相关实验室数据）发送给了24位对中风有特殊兴趣的神经科医生，并要求他们确定最可能的亚型诊断。总体一致性为0.64（kappa [K] = 0.54）。医生之间对心源性栓塞性中风（K = 0.75）或大动脉粥样硬化性中风（K = 0.69）诊断的一致性最高。个体医生之间的差异很大；4位医生在所有18例病例中都同意共识诊断，而另外6位医生在3至5例病例中不同意共识诊断。我们的医生间一致性水平高于其他研究报告的水平，且程度较高。然而，尽管使用了亚型定义并提供了急性情况下通常无法获得的广泛信息，但医生们对于中风的病因仍存在分歧，特别是在小动脉闭塞性中风或病因不明的中风方面。医生们似乎不愿意不将中风归因于特定病因。亚型诊断的不确定性将影响对根据缺血性中风亚型选择的患者进行临床试验结果的解释，也表明除非在试验操作中纳入确保一致性的措施，否则应谨慎解释受亚型影响的治疗结果。改进确定缺血性中风亚型的算法确实能提高医生间的一致性。应严格应用此类标准，并且试验应包括措施以确保尽可能统一地诊断中风亚型。
