Inter-rater reliability of physical abuse determinations in young children with fractures
Inter-rater reliability of physical abuse determinations in young children with fractures
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DOI：
10.1016/j.chiabu.2017.08.001
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发表时间：
2017-10-01
影响因子：
4.8
通讯作者：
Sharkey, Melinda S.
中科院分区：
文献类型：
--
作者：
Buesser, Katherine E.;Leventhal, John M.;Sharkey, Melinda S.
由于在确定骨折是由事故还是虐待引起方面没有“黄金标准”，医疗服务提供者之间的协议至关重要。利用551例儿童急诊< 36个月儿童的医疗记录数据，我们检查了评估疑似虐待骨折儿童的专家之间的一致程度。为了模拟临床场景，两名儿童骨科医生和两名儿童虐待儿科医生（CAPs）回顾了完整的抽象化和成像，而两名儿童放射科医生回顾了简史和成像。每位医生使用7分的顺序量表对每个病例进行独立评分，以区分意外伤害和虐待伤害。对于独立评级的任何差异，两位专家讨论了情况并得出了联合评级。我们分析了三种类型的一致性：(1)使用独立评级的专业内部，(2)使用联合评级的专业之间，以及(3)经验丰富与缺乏经验的临床医生（骨科医生和cap）之间。对评分者之间的一致性使用科恩加权kappa进行评估。骨科医生（k = 0.78）和cap医生（k = 0.67）在专业范围内有很大的一致性，而放射科医生（k = 0.53）有中等一致性。骨科医生和CAPs的专业间一致性几乎是完美的（k = 0.81），而骨科医生和放射科医生（k = 0.37）和CAPs和放射科医生（k = 0.42）的一致性要低得多。经验丰富的临床医生具有显著的专业间一致性（k = 0.80），而经验不足的临床医生具有中度一致性（k = 0.60）。这些发现表明，在评估幼儿骨折时，医生接受的临床细节水平和他/她在该领域的经验会影响一致性的水平。
As there is no "gold standard" in determining whether a fracture is caused by accident or abuse, agreement among medical providers is paramount. Using abstracted medical record data from 551 children < 36 months of age presenting to a pediatric emergency department, we examined the extent of agreement between specialists who evaluate children with fractures for suspected abuse. To simulate clinical scenarios, two pediatric orthopaedists and two child abuse pediatricians (CAPs) reviewed the full abstraction and imaging, whereas the two pediatric radiologists reviewed a brief history and imaging. Each physician independently rated each case using a 7 point ordinal scale designed to distinguish accidental from abusive injuries. For any discrepancy in independent ratings, the two specialists discussed the case and came to a joint rating. We analyzed 3 types of agreement: (1) within specialties using independent ratings, (2) between specialties using joint ratings, and (3) between clinicians (orthopaedists and CAPs) with more versus less experience. Agreement between pairs of raters was assessed using Cohen's weighted kappa. Orthopaedists (k = 0.78) and CAPs (k = 0.67) had substantial within-specialty agreement, while radiologists (k = 0.53) had moderate agreement. Orthopaedists and CAPs had almost perfect between-specialty agreement (k = 0.81), while agreement was much lower for orthopaedists and radiologists (k = 0.37) and CAPs and radiologists (k = 0.42). More-experienced clinicians had substantial between-specialty agreement (k = 0.80) versus less-experienced clinicians who had moderate agreement (k = 0.60). These findings suggest the level of clinical detail a physician receives and his/her experience in the field has an impact on the level of agreement when evaluating fractures in young children.