Interobserver Reliability of the Berlin ARDS Definition and Strategies to Improve the Reliability of ARDS Diagnosis
Interobserver Reliability of the Berlin ARDS Definition and Strategies to Improve the Reliability of ARDS Diagnosis
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DOI：
10.1016/j.chest.2017.11.037
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发表时间：
2018-02-01
期刊：
影响因子：
9.6
通讯作者：
Iwashyna, Theodore J.
中科院分区：
文献类型：
--
作者：
Sjoding, Michael W.;Hofer, Timothy P.;Iwashyna, Theodore J.
背景：未能可靠地诊断 ARDS 可能是临床试验阴性以及临床实践中认识不足和治疗不足的主要原因。我们试图检查柏林 ARDS 定义的观察者间可靠性，并检查提高 ARDS 诊断可靠性的策略。方法：三名临床医生对来自 4 个 ICU 的 205 名缺氧性呼吸衰竭患者进行独立审查，评估患者是否患有 ARDS、审查者的诊断置信度、患者是否符合个体 ARDS 标准以及满足标准的时间。结果：ARDS 诊断的观察者间可靠性为“中等”（kappa = 0.50； 95% CI，0.40-0.59）。临床医生在审查同一患者时，67% 的诊断分歧是由于胸部影像学研究的解释方式不同而造成的，其他 ARDS 标准的贡献较小（识别 ARDS 危险因素，15%；排除心脏水肿/容量超负荷，7%）。结合三位临床医生的独立审查可以将可靠性提高到“实质性”（kappa = 0.75；95% CI，0.68-0.80）。当一名临床医生以“高置信度”诊断 ARDS 时，所有其他临床医生在 72% 的评论中都同意该诊断。如果患者在住院后 48 小时内发生 ARDS，则临床医生对于患者满足所有 ARDS 标准的时间达成了密切一致（中位差为 5 小时）。结论：柏林 ARDS 定义的可靠性为中等，主要是由于胸部影像学解释的差异造成的。结合多个临床医生的独立审查或改进胸部影像学双侧浸润的识别方法是提高 ARDS 诊断可靠性的重要策略。
BACKGROUND: Failure to reliably diagnose ARDS may be a major driver of negative clinical trials and underrecognition and treatment in clinical practice. We sought to examine the interobserver reliability of the Berlin ARDS definition and examine strategies for improving the reliability of ARDS diagnosis.METHODS: Two hundred five patients with hypoxic respiratory failure from four ICUs were reviewed independently by three clinicians, who evaluated whether patients had ARDS, the diagnostic confidence of the reviewers, whether patients met individual ARDS criteria, and the time when criteria were met.RESULTS: Interobserver reliability of an ARDS diagnosis was "moderate" (kappa = 0.50; 95% CI, 0.40-0.59). Sixty-seven percent of diagnostic disagreements between clinicians reviewing the same patient was explained by differences in how chest imaging studies were interpreted, with other ARDS criteria contributing less (identification of ARDS risk factor, 15%; cardiac edema/volume overload exclusion, 7%). Combining the independent reviews of three clinicians can increase reliability to "substantial" (kappa = 0.75; 95% CI, 0.68-0.80). When a clinician diagnosed ARDS with "high confidence," all other clinicians agreed with the diagnosis in 72% of reviews. There was close agreement between clinicians about the time when a patient met all ARDS criteria if ARDS developed within the first 48 hours of hospitalization (median difference, 5 hours).CONCLUSIONS: The reliability of the Berlin ARDS definition is moderate, driven primarily by differences in chest imaging interpretation. Combining independent reviews by multiple clinicians or improving methods to identify bilateral infiltrates on chest imaging are important strategies for improving the reliability of ARDS diagnosis.