Overall Proportion Of Agreement Research Articles

Spinal pain patients seeking care in primary care and referred to physiotherapy: A cross-sectional study on patients characteristics, referral information and physiotherapy care offered by general practitioners and physiotherapists in France

To describe spinal pain patients referred by their treating general practitioners to physiotherapy care, examine to which extent physiotherapy interventions proposed by general practitioners and physiotherapists were compliant to evidence based recommendations, and evaluate concordance between providers in terms of diagnosis and contraindications to physiotherapy interventions. This study included spinal pain patients recruited from a random sample of sixty French physiotherapists. Physiotherapists were asked to supply patients' physiotherapy records and characteristics from the general practitioner's physiotherapy referral for the five new consecutive patients referred to physiotherapy. General practitioner's physiotherapy referral and physiotherapists' clinical findings characteristics were analyzed and compared to evidence-based recommendations using Chi-squared tests. Cohen's kappas were calculated for diagnosis and contraindications to physiotherapy interventions. Three hundred patients with spinal pain were included from sixty physiotherapists across France. The mean age of the patients was 48.0 ± 7.2 years and 53% were female. The most common spinal pain was low back pain (n = 147). Diagnoses or reason of referral formulated by general practitioners were present for 27% of all patients (n = 82). Compared to general practitioners, physiotherapists recommended significantly more frequently recommended interventions such as education, spinal exercises or manual therapy. General practitioners prescribed significantly more frequently passive physiotherapy approaches such as massage therapy and electrotherapy. The overall proportion of agreement beyond chance for identification of a diagnosis or reason of referral was 41% with a weak concordance (κ = 0.19; 95%CI: 0.08-0.31). The overall proportion of compliant physiotherapists was significantly higher than for general practitioners (76.7% vs 47.0%; p<0.001). We found that information required for the referral of spinal pain patients to physiotherapy is often incomplete. The majority of general practitioners did not conform to evidence-based recommendations in terms of prescribed specific physiotherapy care; in contrast to a majority of physiotherapists. ClinicalTrials.gov: NCT04177121.

Validation of evaluating left ventricular diastolic function with estimated left atrial volume from anteroposterior diameter

BackgroundLeft atrial (LA) volume (LAV) is one of the recommended key variables for evaluating left ventricular (LV) diastolic function. However, only LA anteroposterior diameter (LAAP) is available in numerous large-scale existing databases. Therefore, this study aimed to validate whether LV diastolic function could be evaluated with estimated LAV from LAAP.MethodsA total of 552 inpatients with sinus rhythm were consecutively enrolled. LAV was measured by biplane Simpson’s disk summation method. LV diastolic function was evaluated according to the 2016 proposed recommendations. Best-fitting regression models of LAAP index (LAAPI)–LAV index (LAVI) were developed and equations with the highest F-value were chosen in the first 276 subjects (derivation set), and concordance for evaluating LV diastolic function between using estimated and observed LAVI was verified in the remaining 276 subjects (validation set).ResultsIn the derivation set, the linear model has the highest F-value in all subjects and in the subjects with normal or depressed LV ejection fraction. In the validation set, using the linear equation (LAVI = 2.05 × LAAPI − 13.86), the higher area under curve and narrower range of difference were shown between estimated LAVI and observed LAVI, respectively. Further, concordance for diagnosis (overall proportion of agreement, 88.4%; κ = 0.79) and grading (overall proportion of agreement, 84.8%; κ = 0.74) of LV diastolic dysfunction was substantial between using estimated and observed LAVI.ConclusionsLV diastolic function can be evaluated with estimated LAVI from LAAPI, which might provide a surrogate method when the direct measurement of LAV is not available.

Interrater Agreement and Reliability of PERCIST and Visual Assessment When Using 18F-FDG-PET/CT for Response Monitoring of Metastatic Breast Cancer.

Response evaluation at regular intervals is indicated for treatment of metastatic breast cancer (MBC). FDG-PET/CT has the potential to monitor treatment response accurately. Our purpose was to: (a) compare the interrater agreement and reliability of the semi-quantitative PERCIST criteria to qualitative visual assessment in response evaluation of MBC and (b) investigate the intrarater agreement when comparing visual assessment of each rater to their respective PERCIST assessment. We performed a retrospective study on FDG-PET/CT in women who received treatment for MBC. Three specialists in nuclear medicine categorized response evaluation by qualitative assessment and standardized one-lesion PERCIST assessment. The scans were categorized into complete metabolic response, partial metabolic response, stable metabolic disease, and progressive metabolic disease. 37 patients with 179 scans were included. Visual assessment categorization yielded moderate agreement with an overall proportion of agreement (PoA) between raters of 0.52 (95% CI 0.44–0.66) and a Fleiss kappa estimate of 0.54 (95% CI 0.46–0.62). PERCIST response categorization yielded substantial agreement with an overall PoA of 0.65 (95% CI 0.57–0.73) and a Fleiss kappa estimate of 0.68 (95% CI 0.60–0.75). The difference in PoA between overall estimates for PERCIST and visual assessment was 0.13 (95% CI 0.06–0.21; p = 0.001), that of kappa was 0.14 (95% CI 0.06–0.21; p < 0.001). The overall intrarater PoA was 0.80 (95% CI 0.75–0.84) with substantial agreement by a Fleiss kappa of 0.74 (95% CI 0.69–0.79). Semi-quantitative PERCIST assessment achieved significantly higher level of overall agreement and reliability compared with qualitative assessment among three raters. The achieved high levels of intrarater agreement indicated no obvious conflicting elements between the two methods. PERCIST assessment may, therefore, give more consistent interpretations between raters when using FDG-PET/CT for response evaluation in MBC.

Impact of Updated 2016 ASE/EACVI VIS-À-VIS 2009 ASE Recommendation on the Prevalence of Diastolic Dysfunction and LV Filling Pressures in Patients with Preserved Ejection Fraction.

BACKGROUNDAssessment of diastolic dysfunction (DD) and left ventricular filling pressures (LVFP) by echocardiography is complex in patients with preserved ejection fraction (EF). The American Society of Echocardiography and the European Association of Cardiovascular Imaging (ASE/EACVI) jointly published recommendations in 2016 to simplify the diagnosis and classification of DD and the assessment of LVFP. We aimed to study the impact of the updated 2016 ASE/EACVI guidelines vis-à-vis the 2009 ASE recommendations on prevalence of DD and LVFP in patients with preserved EF.METHODSFive hundred patients referred to the echocardiography laboratory from March 2020 to May 2020 were analyzed. Patients with left ventricular ejection fraction (LVEF) < 50% were excluded. All patients underwent comprehensive transthoracic echocardiography. DD and LVFP were assessed by the 2016 ASE/EACVI and 2009 ASE recommendations. The concordance between the guidelines was analyzed by kappa coefficient and overall proportion of agreement.RESULTSMean age was 53 ± 13 years and 63.4% were men. Prevalence of DD and abnormal LVFP were significantly lower with the 2016 recommendations than with the 2009 recommendations (9.4% vs. 16.8%, p < 0.001 and 8.4% vs. 12.8%, p < 0.05). Patients with Grade 1 DD (100%) and Grade 2 DD (46.4%) were reclassified by the 2016 recommendations. Indeterminate diastolic function (9.8%) was strikingly high according to the 2016 recommendations. The concordance between the two recommendations was moderate (kappa = 0.569). The overall proportion of agreement was 85.4%.CONCLUSIONSPrevalence of DD and abnormal LV filling pressures were lower with application of the 2016 ASE/EACVI recommendations in patients with preserved EF. There was moderate agreement between the 2009 and 2016 recommendations.

Practical Impact of New Diastolic Recommendations on Noninvasive Estimation of Left Ventricular Diastolic Function and Filling Pressures

In 2016, an update of the 2009 recommendations for the evaluation of left ventricular (LV) diastolic function (DF) was released by the American Society of Echocardiography and the European Association of Cardiovascular Imaging. The aims of this study were to assess the concordance between the 2016 and 2009 recommendations and to test the impact of the consideration of "myocardial disease" recommended in the 2016 update on the evaluation of diastolic dysfunction (DD) and LV filling pressures in patients with normal and reduced LV ejection fractions referred to a general echocardiography laboratory. A total of 1,508 outpatients referred to an echocardiography laboratory during a predefined 5-month period were prospectively enrolled. All patients underwent targeted clinical history and Doppler echocardiographic examination. DD and LV filling pressures were assessed according to 2009 and 2016 recommendations. Concordance was calculated using the κ coefficient and overall proportion of agreement. Overall proportion of agreement between the two recommendations was 64.7% (κ=0.43). Comparing the 2009 and 2016 recommendations, 47.5% and 36.1% patients, respectively, had DD (P<.0001), and 22.7% and 12.6% had elevated LV filling pressures (P<.0001). This difference remained significant in the setting of patients with normal LV ejection fractions (21.6% vs 10.7%, P<.0001). In the application of the 2016 recommendations, whether or not the presence of "myocardial disease" was considered, the prevalence of indeterminate diastolic function was, respectively, 7.3% versus 13.7%, while patients in whom the DD grade could not be determined were 8.1% versus 14.4% (P<.0001 for all). Considering the presence of myocardial disease when applying the 2016 recommendations resulted in a lower prevalence of inconclusive diagnosis.

P1933Comparing treatment recommendations for the DAPT and PRECISE-DAPT scores after percutaneous coronary intervention

Abstract Background Dual antiplatelet therapy (DAPT), with aspirin and a P2Y12 inhibitor, is the standard therapy for patients following PCI. Duration of treatment with DAPT has been controversial despite large studies. Current guidelines recommend treatment duration be individualized based on risk of ischemia and bleeding. To facilitate treatment decisions, risk assessment tools, including the DAPT and PRECISE-DAPT scores, have been developed. Purpose As components of these scores differ, the variability of recommendation remains unknown. We set to evaluate inter-tool concordance in treatment recommendation in a cohort of patients after PCI. Methods Using data from our local PCI registry, we calculated the PRECISE-DAPT at baseline following PCI and the DAPT after 1 year of treatment for 311 consecutive patients with complete data for both scores to be calculated. Based on their DAPT and PRECISE-DAPT scores, patients were grouped into concordant for long-term treatment (DAPT ≥2 and PRECISE-DAPT &lt;25) or concordant for shortened treatment (DAPT &lt;2 and PRECISE- DAPT ≥25). All other patients were considered discordant. We then performed a concordance analysis using Cohen's kappa to measure degree of agreement. Results Among the 311 patients, mean age was 63.4 (SD 11.6); 245 (79%) were men, 93 (29.9%) had history of a prior MI, 130 (41.8%) were current smokers, 32 (10.3%) had a history of CHF or LVEF &lt;30%, 82 (26.3%) had diabetes and 196 (63.0%) were previously diagnosed with hypertension. Index event consisted of a STEMI in 101 (32.4%), NSTEMI in 93 (29.9%), unstable angina in 27 (8.7%), stable angina in 67 (21.5%) and the remaining 23 (7.4%) had other indications for PCI. Mean DAPT score was 1.52 (SD 1.37). Mean PRECISE-DAPT was 17.65 (SD 12.73). The DAPT recommended long-term treatment for 162 (52.1%) and shortened treatment for 149 (47.9%). The PRECISE-DAPT recommended long-term treatment for 245 (78.9%) and shortened treatment for 66 (21.2%). The overall proportion of agreement between the two risk scores was 56.6% with a Cohen's kappa index of 0.110 (95% CI, 0.017 to 0.204). See Table. Concordance Analysis PRECISE-DAPT Score Recommendation Long Term (N=245) Shortened (N=66) DAPT Score Recommendation Long Term (N=162) 136 (43.7%) 26 (8.4%) Concordant for Long Term Treatment Shortened (N=149) 109 (35%) 40 (12.8%) Concordant for Shortened Treatment Conclusion Comparison of the DAPT score and the PRECISE-DAPT score showed concordance in treatment recommendation in only 56.6% of patients. Given the poor agreement between these tools, prospective concurrent evaluations and correlation to outcomes will be required in future studies.

The Effect of a Geriatric Oncology Clinic on Treatment Decisions in Mexican Older Adults With Cancer.

Geriatric assessment and interventions improve the care of older adults with cancer, but their effect on treatment decision making in resource-limited settings is unknown. We studied the effect of recommendations made by a consultative geriatric oncology clinic on treatment decision making by oncologists in Mexico. Retrospective chart review of 173 consecutive patients with solid tumors referred before treatment initiation to the geriatric oncology clinic at a third-level public hospital in Mexico City between March 2015 and October 2017. Patients were evaluated by a multidisciplinary geriatric oncology clinic, and treatment recommendations were issued to treating oncologists. We determined the overall proportion of agreement between geriatric oncology recommendations and oncologists' treatment decisions. We assessed whether agreement increased when geriatric oncology recommendations were acknowledged in the treating oncologist's clinic note. The homogeneity of agreement was tested using the Stuart-Maxwell test. Median age was 79 years (range = 64-97 years). "Standard treatment" was recommended in 48% of cases, followed by "less intensive treatment" in 32%, and "best supportive care" in 20%. The overall proportion of agreement for the entire population was 80% (κ = 0.69), although agreement was heterogeneous (X2 = 8.16, P = .02). Geriatric oncology recommendations were acknowledged in the treating oncologists' notes in 62% of cases. Overall agreement was higher when the evaluation was acknowledged (83%, κ = 0.74) than when it was not acknowledged (74%, κ = 0.60). Agreement was homogeneous only when recommendations were acknowledged in the oncologist's note (X2 = 3.0, P = .22). The overall proportion of agreement between geriatric oncology recommendations and final treatment decisions was high, particularly when recommendations were acknowledged in the treating oncologists' note. Including geriatric oncology evaluations in everyday clinical practice and fostering interdisciplinary communication between geriatric oncology and treating oncologists may provide valuable guidance for physicians caring for older patients with cancer in resource-limited settings. J Am Geriatr Soc 67:992-997, 2019.

Management of incidental aneurysms: comparison of single Centre multi-disciplinary team decision making with the unruptured incidental aneurysm treatment score

Objective: To compare multidisciplinary team (MDT) decision making at our centre with the suggested management from the recently published Unruptured Intracranial Aneurysm Treatment Score (UIATS), with particular focus on disagreements between the two bodies of expert opinion.Design: A retrospective audit of local practice.Subjects: Adult patients with incidental cerebral saccular aneurysms referred to The National Hospital for Neurology and Neurosurgery Neurovascular MDT.Methods: Review of MDT records from 2010–2015 and collection of UIATS criteria. MDT decisions for each aneurysm were designated as conservative or treatment group, then assessed for correlation with the UIATS.Results: Data was collected on 398 aneurysms from 296 patients. 57% of aneurysms were managed conservatively and 43% were treated with endovascular or open repair. Total follow up was 8409 aneurysm months (mean: 21 months per aneurysm). The overall proportion of agreement (p0) was 66.6% (95% CI: 61.9–71.2). Cohen’s Kappa (k) was 0.325 suggesting only a “fair” level of agreement between the two raters. Absolute agreement rates increased from 60% in 2010 to 74% in 2015. Aneurysm size was an important factor for disagreement, 77% of aneurysms treated following MDT, but not in agreement with the UIATS, were >7 mm, compared with only 70.5% in those treated following MDT and in agreement with UIATS.Conclusion: There was disagreement between the two expert opinions analysed in this study. A key factor was aneurysm size, with decision making at our centre seemingly more guided by older landmark papers such as work by the International Study of Unruptured Intracranial Aneurysms (ISUIA) group. However, agreement was at its highest at the end of the study period, suggesting increasing convergence between the two bodies of expert opinion. The reasons for disagreement and particularly clinicians’ reliance on aneurysm size in decision making is something that needs consideration when planning and auditing aneurysm services.

Reliability of test procedures for postural reactions in people with acute stroke

Background/Aims:Regaining and maintaining balance requires postural reactions such as righting reactions, equilibrium reactions, and protective reactions. There is a lack of uniform, standardised, and reliable testing procedures for postural reactions. The aim of the present study was to examine the intra- and interrater reliability of a newly developed postural reactions assessment for use in people with acute stroke.Methods:The Postural Reactions Test was developed based on the literature, on previous tests, and on input from an expert panel. A total of 10 physiotherapists assessed a total of 20 video recordings of people with acute stroke performing each postural reaction. These assessments were carried out on two occasions at least 2 weeks apart. The study thus included 400 ratings.Findings:For intrarater reliability, the overall proportion of agreement was 86 − 93% for the different postural reactions. For interrater reliability, the most common score for each participant and the number of physiotherapists giving that score were noted. A median of 9–10 out of 10 physiotherapists scored the same value.Conclusions:The results indicate that the Postural Reactions Test can be used to reliably assess function in people with acute stroke and that the test can complement the existing assessments for people with affected postural control.

Quality of nursing intensity data: inter-rater reliability of the patient classification after two decades in clinical use.

The aim of this study was to measure the inter-rater reliability of the Oulu Patient Classification and to discuss existing methods of reliability testing. The Oulu Patient Classification, part of the RAFAELA® System, has been developed to assist nursing managers with the proper allocation of nursing resources. Due to the increased intensity of inpatient care during recent years, there is a need for the reliability testing of the classification, which has been in clinical use for 20years. Retrospective statistical study. To test inter-rater reliability, a pair of nurses classified the same patients, without knowledge of each other's ratings, as a part of annually conducted standardization. Data on the parallel classifications (n=19,997) was obtained from inpatient units (n=32) with different specialties at a university hospital in Finland during 2010-2015. Parallel classification practices were also analysed. The reliability of the overall classification and its subareas were calculated using suitable statistical coefficients. Inter-rater reliability coefficients were a reliable or almost perfect means of considering the nursing intensity category and various practices, but there were detectable differences between subareas. The lowest agreement levels occurred in the subareas 'Planning and Coordination of Nursing Care' and 'Guiding of Care/Continued Care and Emotional Support'. There is a need to develop the descriptions of subareas and to clarify the related concepts. Precise nursing documentation can promote a high level of agreement and reliable results. The traditional overall proportion of agreement does not provide an adequate picture of reliability - weighted kappa coefficients should be used instead.

Comparison of CTA- and DSA-Based Collateral Flow Assessment in Patients with Anterior Circulation Stroke.

Collateral flow is associated with clinical outcome after acute ischemic stroke and may serve as a parameter for patient selection for intra-arterial therapy. In clinical trials, DSA and CTA are 2 imaging modalities commonly used to assess collateral flow. We aimed to determine the agreement between collateral flow assessment on CTA and DSA and their respective associations with clinical outcome. Patients randomized in MR CLEAN with middle cerebral artery occlusion and both baseline CTA images and complete DSA runs were included. Collateral flow on CTA and DSA was graded 0 (absent) to 3 (good). Quadratic weighted κ statistics determined agreement between both methods. The association of both modalities with mRS at 90 days was assessed. Also, association between the dichotomized collateral score and mRS 0-2 (functional independence) was ascertained. Of 45 patients with evaluable imaging data, collateral flow was graded on CTA as 0, 1, 2, 3 for 3, 10, 20, and 12 patients, respectively, and on DSA for 12, 17, 10, and 6 patients, respectively. The κ-value was 0.24 (95% CI, 0.16-0.32). The overall proportion of agreement was 24% (95% CI, 0.12-0.38). The adjusted odds ratio for favorable outcome on mRS was 2.27 and 1.29 for CTA and DSA, respectively. The relationship between the dichotomized collateral score and mRS 0-2 was significant for CTA (P = .01), but not for DSA (P = .77). Commonly applied collateral flow assessment on CTA and DSA showed large differences, indicating that these techniques are not interchangeable. CTA was significantly associated with mRS at 90 days, whereas DSA was not.

Agreement on intrapartum cardiotocogram recordings between expert obstetricians.

To evaluate obstetricians' inter- and intra-observer agreement on intrapartum cardiotocogram (CTG) recordings and to examine obstetricians' evaluations with respect to umbilical artery pH and base deficit. Nine experienced obstetricians annotated 634 intrapartum CTG recordings. The evaluation of each recording was divided into four steps: evaluation of two 30-minute windows in the first stage of labour, evaluation of one window in the second stage of labour and labour outcome prediction. The complete set of evaluations used for this experiment is available online. The inter- and intra-observer agreement was evaluated using proportion of agreement and kappa coefficient. Clinicians' sensitivity and specificity was computed with respect to umbilical artery pH, base deficit and to Apgar score at the fifth minute. The overall proportion of agreement between clinicians reached 48% with 95% confidence intervals (CI) (CI: 47-50). Regarding the different classes, proportion of agreement ranged from 57% (CI: 54-60) for normal to 41% (CI: 36-46) for pathological class. The sensitivity of clinicians' majority vote to objective outcome was 39% (CI: 16-63) for the umbilical artery base deficit and 27% (CI: 16-42) for pH. The specificity was 89% (CI: 86-92) for both types of objective outcome. The reported inter-/intra-observer variability is large and this holds irrespective of clinicians' experience or work place. The results support the need of modernized guidelines for CTG evaluation and/or objectivization and repeatability by introduction of a computerized approach that could standardize the process of CTG evaluation within the delivery ward.

Comparison of lavage and swabs for the collection of genital ulcer specimens to measure HIV RNA shedding

Background The optimum collection procedure for the evaluation of HIV-1 burden in ulcer secretions has not been well defined. Objectives The objective of this study was to compare ulcer swabs and ulcer lavages for the detection and quantitation of HIV-1 RNA in genital ulcers. Study design A convenience sample of the first 84 HIV-positive participants in a randomized double blind placebo controlled trial of acyclovir episodic treatment among men with genital ulcer disease were included in this evaluation. At baseline, participants were screened for HIV, syphilis and HSV-2 by serology and for ulcer etiology by PCR. Ulcer specimens were collected by using (1) a non-traumatic washing procedure with 10 ml of PBS, and (2) sterile dry swabs. Ulcer samples were tested with HIV-1 Amplicor 1.5 Ultra Sensitive Assay with a lower threshold of 50 copies/ml. Results Of ulcer samples 35 (41.7%) had HIV detected by ulcer lavage and 32 (38.1%) by swabs ( p = 0.68). Overall, 45 (53.6%) were positive by one or both methods. The overall proportion of agreement was 73% (61/84). The chance-corrected proportion of agreement was 0.46 (95% CI: 0.26, 0.65) as estimated by the Kappa statistic. The log mean viral load from lavages (1.49 log 10 copies/ml, 95% CI: 1.17–1.81) did not differ significantly from that of swabs (1.41 log 10 copies/ml, 95% CI: 1.16–1.71) ( p = 0.29) with a mean difference of 0.08 log copies/ml (SD 0.96) . Conclusion Ulcer lavage and ulcer swab performed in moderate agreement in the detection and quantitation of HIV RNA from ulcer specimens.

Die Interrater-Reliabilität der Braden-Skala

Pressure ulcer risk assessment scales can assist nurses in determining the individual pressure ulcer risk. Although the Braden scale is widely used throughout Germany, its psychometric properties are yet unknown. The aim of the study was to determine the interrater reliability of the Braden scale and to compare the results with those of published data. A literature review was conducted. 20 studies measuring the interrater reliability of the Braden scale were evaluated. Only three of those studies investigated the interrater reliability of single items. The Pearson product-moment correlation coefficient (0.80 to 1.00) was calculated in most studies for an evaluation of the Braden scale as a whole. However, the use of correlation coefficients is inappropriate for measuring the interrater reliability of the Braden scale. Measures of the intraclass correlation coefficient varied from 0.83 to 0.99. The investigation of the interrater reliability of the Braden scale's German version was conducted in a German nursing home in 2006. Nurses independently rated 18 and 32 residents twice. Nurses achieved the highest agreement when rating the items "friction and shear" and "activity" (overall proportion of agreement = 0.67 to 0.84, Cohen's Kappa = 0.57 to 0.73). The lowest agreement was achieved when the item "nutrition" (overall proportion of agreement = 0.47 to 0.51, Cohen's Kappa = 0.28 to 0.30) was rated. For 66% of the rated residents the difference in the obtained Braden scores was equal or less than one point. Intraclass correlation coefficients were 0.91 (95% confidence interval 0.82 to 0.96) and 0.88 (95% confidence interval 0.61 to 0.96). This indicates that the interrater reliability of the Braden scale was high in the examined setting.

Assessment of change of optic nerve head cupping in pediatric glaucoma using the RetCam 120

To ascertain the interobserver agreement among various specialists when analyzing images of the optic nerve head taken with the RetCam 120 (Clarity Medical Systems, Inc., Pleasanton, CA) for assessing the progression of optic disk cupping in pediatric glaucoma. Five observers compared pairs of RetCam 120 two-dimensional photographs from 64 eyes to identify whether or not changes in the optic disk had occurred. Observers included a pediatric glaucoma specialist, pediatric neurophthalmologist, strabismologist, pediatric ophthalmic imaging specialist, and pediatric ophthalmology fellow. Each was masked to the patient identity and clinical course. For each patient, the observers reviewed the photographs taken prior to therapy and at a minimum of 6 months following initiation of therapy. Interobserver variability was calculated and analysis conducted to identify influential variables. Poor agreement was noted between the observers. No significant association was obtained between agreement level and variables affecting photographic quality: variability of contrast and illumination, exposure and magnification, image clarity, presence of fluorescein on the cornea, and pixelation of the image with poor resolution. Raters noted problems with these image variables in 75.6% of the observations. The Kappa statistic obtained was kappa = 0.29 with overall proportion of agreement of p = 0.69, suggesting a fair agreement but not a moderate agreement. Comparison of RetCam 120 pediatric optic nerve head photographs, when performed subjectively by observers with different perspectives, and in isolation from clinical information, may not be a reliable indicator of cupping change. In addition, variations in image contrast, luminance, color, and pixelation pose significant challenges to agreement between observers. Comparison of RetCam 120 images should not be considered the sole criterion for monitoring pediatric glaucoma.

Race/ethnicity in medical charts and administrative databases of patients served by community health centers

The objective of this study was to measure the agreement in classification of patients' race/ethnicity in the medical charts and the automated practice management systems (PMSs) of seven community health centers. Community health centers are on the frontlines of providing primary care to the under-served and racial/ethnic minorities. Public and private investments in information technology and the increasing use of automated disease registries hold promise to improve care and reduce ethnic and racial disparities. However, data quality may limit the accuracy of race/ethnicity classification and the ability to measure the effect of population-based clinical quality improvements. In a cross-sectional study, a probability sample of 947 patients with encounters in 2002 was selected from 79,119 patients. Each PMS used a single data field with a pick list that combined ethnicity and race. Race/ethnicity on registration forms completed by patients was abstracted from medical charts. Race/ethnicity classifications were aggregated into seven major categories: Asian/Pacific Islander, Black/African-American, Native American, White, Hispanic/Latino, Other, Missing/Unknown. The sensitivity, positive predictive value, and proportion of agreement were outcome measures of agreement between information in the medical chart and PMS. The overall proportion of agreement (PA) between the medical chart (reference) and PMS was 87%. The PA varied significantly by health center (95%-74%). Hispanic/Latino had the highest sensitivity (91%) and positive predictive value (95%) and White the lowest (84% and 80%, respectively). In broad categories, correspondence of race/ethnicity classifications in medical charts and PMS was good, although health centers varied. A careful appraisal of data quality of race/ethnicity is warranted before administrative databases are used in clinical quality improvement programs or research to assess health disparities.

Reproducibility of Protected Brush Catheter Specimen Cultures in Critically Ill Patients with Suspected Nosocomial Pneumonia

OBJECTIVE: To determine the reproducibility of two protected brush catheter (PBC) specimens obtained during the same bronchoscopy in critically ill patients with suspected ventilator associated pneumonia.DESIGN: Prospective, observational study.SETTING: Two university-affiliated multidisciplinary intensive care un its with a combined total of 50 beds.PATIENTS: A total of 75 (50 male. 25 female) patients with 84 episodes of suspected ventilator associated pneumonia were studied be tween January 1, 1991 and June 30, 1992. Age was 60.7±1.9 (mean ± SEM) years, and mean APACHE II score was 22.4±2.0. Twenty-four patients were admitted from various medical services, 19 from surgical services including the operating room, 16 with central nervous system disease and 16 following multiple trauma. Twenty patients were transferred directly to the intensive care unit from peripheral hospitals.INTERVENTIONS: All patients had lower respiratory tract secretions obtained for culture by both aspiration through the endotracheal n1be (tracheal aspirates) and flexible bronchoscopy, with separate samples obtained by two PBCs (PBC-A and PBC-8).MAIN RESULTS: The overall proportion of agreement between the results of t he two PBC specimens was 0.928, with a calculated kappa statistic (κ) = 0.853 (P&lt;0.01 versus κ=0.4, 95% CL 0.692, 1.014) indicating excellent agreement between the two specimens. Both PBC specimens had significant (ie, more than 103colony-forming units/mL) growth (positive/positive) in 33 cases, nonsignificant growth in 45 cases (negative/negative) and discordant results in six (positive/negative, n=3 or negative/positive, n=3 ). There was a significant relationship (P&lt;0.05) between the concurrent use of antibiotics and a negative PBC result. However, after exclusion of patients on antibiotics, the overall proportion of agreement between the two PBCs was 0.94 with κ=0.875 (P&lt;0.01 versus κ=0.4, 95% CL 0.721, 1.029), which also indicates excellent agreement between the two tests.CONCLUSIONS: Although discordant results were observed in 7.2% cases, the overall reproducibility of the PBC results appears to be high. The significant relationship between concurrent antibiotic use and a negative PBC result is of concern clinically since many patients arc being treated with antibiotics al the time of bronchoscopy. Therefore, when the diagnosis of nosocomial pneumonia in critically ill patients is established, the PBC result should be considered only in association with all the other clinical data, particularly in patients receiving concurrent antibiotics.