INTERPHYSICIAN AGREEMENT IN THE DIAGNOSIS OF SUBTYPES OF ACUTE ISCHEMIC STROKE - IMPLICATIONS FOR CLINICAL-TRIALS
INTERPHYSICIAN AGREEMENT IN THE DIAGNOSIS OF SUBTYPES OF ACUTE ISCHEMIC STROKE - IMPLICATIONS FOR CLINICAL-TRIALS
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DOI：
10.1212/wnl.43.5.1021
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发表时间：
1993-05-01
期刊：
影响因子：
9.9
通讯作者：
GORDON, DL
中科院分区：
文献类型：
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作者：
GORDON, DL;BENDIXEN, BH;GORDON, DL
为了检验医师间对缺血性卒中亚型诊断的一致性，我们将亚型定义和18个病例摘要（临床特征和相关实验室数据）发送给24位对卒中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）。在继发于心脏栓塞（K = 0.75）或大动脉粥样硬化（K = 0.69）的中风诊断中，医师间的一致性最高。医生个体差异很大；在所有18例中，有4例同意一致诊断，而在3至5例中，有6例不同意一致诊断。我们的医师间共识水平比其他研究报道的要高，而且是实质性的。然而，尽管使用了亚型定义，并提供了大量的信息，但在急性情况下往往无法获得，医生们仍然对中风的病因存在分歧，特别是关于小动脉闭塞或病因不明的中风。医生似乎不愿意将中风归因于特定的病因。亚型诊断的不确定性将影响对缺血性卒中亚型患者的临床试验结果的解释，也表明，除非在试验操作中努力确保一致性，否则受亚型影响的治疗结果应谨慎解释。确定缺血性脑卒中亚型的算法的改进确实提高了医师间的一致性。这些标准应严格适用，试验应包括确保卒中亚型的最统一诊断的措施。
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.