Raw Agreement Research Articles

Feasibility of an Assessment Tool for Children's Competence to Consent to Predictive Genetic Testing: a Pilot Study.

Knowledge on children’s capacities to consent to medical treatment is limited. Also, age limits for asking children’s consent vary considerably between countries. Decision-making on predictive genetic testing (PGT) is especially complicated, considering the ongoing ethical debate. In order to examine just age limits for alleged competence to consent in children, we evaluated feasibility of a standardized assessment tool, and investigated cutoff ages for children’s competence to consent to PGT. We performed a pilot study, including 17 pediatric outpatients between 6 and 18 years at risk for an autosomal dominantly inherited cardiac disease, eligible for predictive genetic testing. The reference standard for competence was established by experts trained in the relevant criteria for competent decision-making. The MacArthur Competence Assessment Tool for Treatment (MacCAT-T) served as index test. Data analysis included raw agreement between competence classifications, difference in mean ages between children judged competent and judged incompetent, and estimation of cutoff ages for judgments of competence. Twelve (71 %) children were considered competent by the reference standard, and 16 (94 %) by the MacCAT-T, with an overall agreement of 76 %. The expert judgments disagreed in most cases, while the MacCAT-T judgments agreed in 65 %. Mean age of children judged incompetent was 9.3 years and of children judged competent 12.1 years (p = .035). With 90 % sensitivity, children younger than 10.0 years were judged incompetent, with 90 % specificity children older than 11.8 years were judged competent. Feasibility of the MacCAT-T in children is confirmed. Initial findings on age cutoffs are indicative for children between the age of 12 and 18 to be judged competent for involvement in the informed consent process. Future research on appropriate age-limits for children’s alleged competence to consent is needed.

Definition and Classification of Intraoperative Complications (CLASSIC): Delphi Study and Pilot Evaluation.

Standardized reporting of intraoperative adverse events is important to enhance transparency. To the best of our knowledge, there is no validated definition and classification of intraoperative complications. We conducted a two-round Delphi study to develop a definition and classification of intraoperative complications. Experts were contacted by email and sent a link to the online questionnaire. In a pilot study, two independent raters applied the definition and classification in a sample of 60 surgical interventions of low, intermediate, and high complexity and evaluated practicability. Interrater agreement of the classification was determined (raw categorical agreement, weighted kappa, and intraclass correlation). In the Delphi study, 40 of 52 experts (77 % return rate) from 14 countries took part in each round. The Delphi study resulted in a comprehensive definition of intraoperative complications as any deviation from the ideal intraoperative course occurring between skin incision and skin closure. The classification foresees four grades depending on the need for treatment (no need, grade I; need for treatment, grade II) and the severity of the complication (life-threatening/permanent disability, grade III; death, grade IV). The pilot study showed good practicability (6 on a 7-point scale) and a high raw agreement of 87 %, a weighted kappa of 0.83 [95 % confidence interval (CI) 0.73-0.94] and an intraclass correlation coefficient of 0.83 (95 % CI 0.73-0.90). While the Delphi process enabled to develop definitions and classification of intraoperative complications by severity, further research including a multicentre international full-scale validation needs to be conducted with the ultimate goal to contribute to standardized reporting in surgical practice and research.

Detecting Facet Joint and Lateral Mass Injuries of the Subaxial Cervical Spine in Major Trauma Patients.

Study DesignRadiologic imaging measurement study.PurposeTo assess the accuracy of detecting lateral mass and facet joint injuries of the subaxial cervical spine on plain radiographs using computed tomography (CT) scan images as a reference standard; and the integrity of morphological landmarks of the lateral mass and facet joints of the subaxial cervical spine.Overview of LiteratureInjuries of lateral mass and facet joints potentially lead to an unstable subaxial cervical spine and concomitant neurological sequelae. However, no study has evaluated the accuracy of detecting specific facet joint injuries.MethodsEight spinal surgeons scored four sets of the same, randomly re-ordered, 30 cases with and without facet joint injuries of the subaxial cervical spine. Two surveys included conventional plain radiographs series (test) and another two surveys included CT scan images (reference). Facet joint injury characteristics were assessed for accuracy and reliability. Raw agreement, Fleiss kappa, Cohen's kappa and intraclass correlation coefficient statistics were used for reliability analysis. Majority rules were used for accuracy analysis.ResultsOf the 21 facet joint injuries discerned on CT scan images, 10 were detected in both plain radiograph surveys (sensitivity, 0.48; 95% confidence interval [CI], 0.26-0.70). There were no false positive facet joint injuries in either of the first two X-ray surveys (specificity, 1.0; 95% CI, 0.63-1.0). Five of the 11 cases with missed injuries had an injury below the lowest visible articulating level on radiographs. CT scan images resulted in superior inter- and intra-rater agreement values for assessing morphologic injury characteristics of facet joint injuries.ConclusionsPlain radiographs are not accurate, nor reliable for the assessment of facet joint injuries of the subaxial cervical spine. CT scans offer reliable diagnostic information required for the detection and treatment planning of facet joint injuries.

Interrater Reliability of Motion Palpation in the Thoracic Spine.

Introduction. Manual therapists commonly use assessments of intervertebral motion to determine the need for spinal manipulation, but the reliability of these procedures demonstrates conflicting results. The objectives of this study were to investigate the interrater reliability of thoracic spine motion palpation for perceived joint restriction and pain. Methods. Twenty-five participants between the ages of 18 and 70, with or without mid-back pain, were enrolled. Two raters motion palpated marked T5–T12 levels using two methods (standardised and pragmatic) and noted any restricted or painful segments. We calculated agreement between two raters by generating raw agreement percentages and Kappa coefficients with 95% confidence intervals. Results. There was poor to low level of agreement between the raters for both joint stiffness and pain localization using both pragmatic and standardized approaches. The results did not improve significantly when we conducted a post hoc analysis where three spinal levels were collapsed as one and right and left sides were also combined. Conclusions. The results for interrater reliability were poor for motion restriction and pain. These findings may have unfavourable implications for all manual therapists who use motion palpation to select patients appropriate for spinal manipulation.

PERJANJIAN BAKU MENURUT PRINSIP SYARIAH (Tinjauan Yuridis Praktik Pembiayaan di Perbankan Syariah)

Nowadays many economic transactions conducted through the bank. In Indonesia, the banks can be divided into two, namely conventional banks and Islamic banks. The development of financing in Islamic banks illustrates that this product enjoyed by many people. To that end, the Islamic banking is necessary to a healthy financial services and in accordance with Islamic principles. This paper aims to assess How raw agreement according to Islamic principles and what the legal consequences of raw agreement on financing in Islamic banking for the parties. This paper uses the type of normative research to conduct legal interpretation of the material to obtain a solution to the problem. Results and discussion shows that raw raw agreement has been made legally, but do not pay attention to one of the Islamic principles set out in the acceptance of products and product distribution of funds in Islamic banking, the balance (tawâzun). Standard contract after an analysis according to Islamic principles, including the damaged or imperfect agreement because the agreement has been made legally, but there is one principle which is not fulfilled then make the agreement unenforceable. imperfect agreement did not result in legal consequences for the parties

Three-Dimensional Navigation Is More Accurate than Two-Dimensional Navigation or Conventional Fluoroscopy for Percutaneous Sacroiliac Screw Fixation in the Dysmorphic Sacrum

To evaluate the accuracy of computer-assisted sacral screw fixation compared with conventional techniques in the dysmorphic versus normal sacrum. Review of a previous study database. Database of a multinational study with 9 participating trauma centers. The reviewed group included 130 patients, 72 from the navigated group and 58 from the conventional group. Of these, 109 were in the nondysmorphic group and 21 in the dysmorphic group. Placement of sacroiliac (SI) screws was performed using standard fluoroscopy for the conventional group and BrainLAB navigation software with either 2-dimensional or 3-dimensional (3D) navigation for the navigated group. Accuracy of SI screw placement by 2-dimensional and 3D navigation versus conventional fluoroscopy in dysmorphic and nondysmorphic patients, as evaluated by 6 observers using postoperative computerized tomography imaging at least 1 year after initial surgery. Intraobserver agreement was also evaluated. There were 11.9% (13/109) of patients with misplaced screws in the nondysmorphic group and 28.6% (6/21) of patients with misplaced screws in the dysmorphic group, none of which were in the 3D navigation group. Raw agreement between the 6 observers regarding misplaced screws was 32%. However, the percent overall agreement was 69.0% (kappa = 0.38, P < 0.05). The use of 3D navigation to improve intraoperative imaging for accurate insertion of SI screws is magnified in the dysmorphic proximal sacral segment. We recommend the use of 3D navigation, where available, for insertion of SI screws in patients with normal and dysmorphic proximal sacral segments. Therapeutic level I.

Interrater agreement for two systems used to determine the probability of heparin-induced thrombocytopenia.

The interrater reliability of the 4T's method and the HIT expert probability (HEP) score for clinical evaluation of suspected heparin-induced thrombocytopenia (HIT) was investigated. Patients hospitalized over a three-year period who were tested for HIT via anti-platelet factor 4 (anti-PF4) antigen assay were identified using laboratory data; 127 patient cases met the study inclusion criteria. Nine clinical pharmacists with expertise in HIT management evaluated the 127 cases using two pretest scoring systems: the 4T's score and the HEP score. Each case was independently evaluated using both 4T's and HEP scores. The primary endpoint was interrater agreement of overall 4T's and HEP scores and individual item scores. Raw agreement of values assigned by the two raters for each of the four items comprising the 4T's score ranged from 0.54 to 0.86, with agreement of 0.63 for final patient categorizations. Raw agreement of rater weightings of the eight HEP scoring items ranged from 0.34 to 1.0; for dichotomization of patients at the suggested screening cutoff value (>2.0), agreement was 0.65. Kappa coefficients were 0.15-0.45 for 4T's item scores and 0.17-0.70 for HEP score item scores. With both scoring systems, low rater agreement mainly related to determination of the timing of thrombocytopenia and possible other causes of the disorder. In a retrospective study, inter-rater agreement in scoring of HIT probability via the 4T's and HEP scoring systems was relatively low. The HEP score did not increase interrater reliability or correlation with anti-PF4 antibodies compared with the 4T's score.

Abstract 16887: Impact of Variability in Echocardiographic Interpretation on Assessment of Repair Following Congenital Heart Surgery

Background: Technical Performance Score (TPS), a tool based largely on the presence and magnitude of residua on postoperative echocardiograms (echo), has been used for assessing surgical repair and correlates with outcomes. The reproducibility of the echo measures that drive TPS classification has not been tested. We evaluated reader variability for echo components of TPS for tetralogy of Fallot (TOF) repair and arterial switch operation (ASO) in 2 centers and measured its effect on TPS. Hypothesis: Inter-reader echo measurement variability will not substantially impact TPS classification. Methods: Postoperative echos were evaluated in 67 subjects (39 TOF and 28 ASO). Two readers (1 per center) read each echo, blinded to center of origin. To assess intra-reader variability, 25% of echoes were re-reviewed by each reader. Measurements between readers were compared with Intra-class correlation (ICC). TPS Class (1 Optimal no residua , 2 Adequate minor residua , 3 Inadequate major residua ) was assigned for each echo review by an independent investigator. The impact of measurement variability on overall TPS variability was compared using weighted Kappa (K) and % raw agreement. Results: ICC was highest for Doppler velocity data and lower for measurements of small linear structures such as septal defects and vena contracta Figure. Overall TPS demonstrated good agreement (between reader TOF K = 0.82 and ASO K = 0.81). The 2 readers were concordant for TPS Class for 53 subjects (79%) and discordant for Classes 2 vs. 3 in 6 (9%); no readings were discordant between Classes 1 and 3 Table . Conclusions: Although overall TPS demonstrated good agreement, inter-reader variation for echo measurements had a small, but important effect on TPS for ASO and TOF, particularly for the distinction between minor and major residua. Future studies of generalizability and reproducibility of TPS across centers and lesions are needed before TPS could be adopted as a national quality measure.

EasyDIAg: A tool for easy determination of interrater agreement

Reliable measurements are fundamental for the empirical sciences. In observational research, measurements often consist of observers categorizing behavior into nominal-scaled units. Since the categorization is the outcome of a complex judgment process, it is important to evaluate the extent to which these judgments are reproducible, by having multiple observers independently rate the same behavior. A challenge in determining interrater agreement for timed-event sequential data is to develop clear objective criteria to determine whether two raters' judgments relate to the same event (the linking problem). Furthermore, many studies presently report only raw agreement indices, without considering the degree to which agreement can occur by chance alone. Here, we present a novel, free, and open-source toolbox (EasyDIAg) designed to assist researchers with the linking problem, while also providing chance-corrected estimates of interrater agreement. Additional tools are included to facilitate the development of coding schemes and rater training.

Microscopical characterization of carbon materials derived from coal and petroleum and their interaction phenomena in making steel electrodes, anodes and cathode blocks for the Microscopy of Carbon Materials Working Group of the ICCP

This paper describes the evaluation of petrographic textures representing the structural organization of the organic matter derived from coal and petroleum and their interaction phenomena in the making of steel electrodes, anodes and cathode blocks.This work represents the results of the Microscopy of Carbon Materials Working Group in Commission III of the International Committee for Coal and Organic Petrology between the years 2009 and 2013. The round robin exercises were run on photomicrograph samples. For textural characterization of carbon materials the existing ASTM classification system for metallurgical coke was applied.These round robin exercises involved 15 active participants from 12 laboratories who were asked to assess the coal and petroleum based carbons and to identify the morphological differences, as optical texture (isotropic/anisotropic), optical type (punctiform, mosaic, fibre, ribbon, domain), and size. Four sets of digital black and white microphotographs comprising 151 photos containing 372 fields of different types of organic matter were examined. Based on the unique ability of carbon to form a wide range of textures, the results showed an increased number of carbon occurrences which have crucial role in the chosen industrial applications.The statistical method used to evaluate the results was based on the “raw agreement indices”. It gave a new and original view on the analysts' opinion by not only counting the correct answers, but also all of the knowledge and experience of the participants. Comparative analyses of the average values of the level of overall agreement performed by each analyst in the exercises during 2009–2013 showed a great homogeneity in the results, the mean value being 90.36%, with a minimum value of 83% and a maximum value of 95%.

Inter-observer agreement of spontaneous breathing trial outcome.

Spontaneous breathing trials (SBTs) are a very important test in the weaning process. The trial involves evaluation of multiple objective and subjective variables. These characteristics could lead to variability in interpreting outcomes with important clinical implications. We aimed to measure the inter-observer agreement between respiratory therapists when analyzing SBT outcomes. In the context of a respiratory therapist-driven weaning protocol, 2 respiratory therapists independently interpreted the subjective variables (use of accessory muscles, agitation, and diaphoresis) and the overall outcome of SBTs (success vs failure) performed in adult subjects mechanically ventilated for any duration. Raw agreements between respiratory therapists and kappa statistics were calculated. One-hundred fifty-one SBTs were interpreted. The overall trial outcome raw agreement was 93.3% (95% CI 88.2-96.3) and kappa 0.63 (95% CI 0.47-0.79). Raw agreement for subjective variables ranged between 92.1% (agitation) and 99.3% (diaphoresis). The group with disagreements in overall trial outcome had higher breathing frequency, breathing-frequency-to-tidal-volume ratio, and systolic blood pressure prior to the trial. Within a respiratory therapist-driven weaning protocol, we found a near 90% inter-observer agreement in the interpretation of SBT outcomes. Our findings illustrate the complexity of interpreting fluctuating subjective and objective variables and their integration into one result: SBT success versus failure. Refining the definitions of variables and their limits for failure along with education might reduce this variability.

Heparin-induced thrombocytopenia in the critically ill: Interpreting the 4Ts test in a randomized trial

BackgroundThrombocytopenia occurs in 20% to 45% of critically ill medical-surgical patients. The 4Ts heparin-induced thrombocytopenia (HIT) score (with 4 domains: Thrombocytopenia, Timing of thrombocytopenia, Thrombosis and oTher reason[s] for thrombocytopenia) might reliably identify patients at low risk for HIT. Interobserver agreement on 4Ts scoring is uncertain in this setting. ObjectiveTo evaluate whether a published clinical prediction rule (the “4Ts score”) reliably rules out HIT in “low-risk” intensive care unit (ICU) patients as assessed by research coordinators (who prospectively scored) and 2 adjudicators (who scored retrospectively) during an international heparin thromboprophylaxis trial (PROTECT, NCT00182143). MethodsOf 3746 medical-surgical ICU patients in PROTECT, 794 met the enrollment criteria for this HIT substudy. Enrollment was predicated on one of the following occurring in ICU: platelets less than 50 × 109/L, platelets decreased to 50% of ICU admission value (if admission value <100 × 109/L), any venous thrombosis, or if HIT was otherwise clinically suspected. Independently, 4Ts scores were completed in real time by research coordinators blinded to study drug and laboratory HIT results, and retrospectively by 2 adjudicators blinded to study drug, laboratory HIT results, and research coordinators' scores; the adjudicators arrived at consensus in all cases. Of the 763 patients, 474 had a central or local laboratory HIT test performed and had 4Ts scoring by adjudicators; 432 were scored by trained research coordinators. Heparin-induced thrombocytopenia was defined by a centrally performed positive serotonin release assay (SRA). ResultsOf the 474 patients with central adjudication, 407 (85.9%) had a 4Ts score of 3 or lower, conferring a low pretest probability (PTP) of HIT; of these, 6 (1.5% [95% confidence interval, 0.7%-3.2%) had a positive SRA. Fifty-nine (12.4%) had a moderate PTP (4Ts score of 4-5); of these, 4 (6.8%) had a positive SRA. Eight patients had a high PTP (4Ts score of ≥6); of these, 1 (12.5%) had a positive SRA. Raw agreement between research coordinators and central adjudication on each domain of the 4Ts score and low, intermediate, and high PTP was good. However, chance-corrected agreement was variable between adjudicators (weighted κ values of 0.31-0.93) and between the adjudicator consensus and research coordinators (weighted κ values of 0.13 and 0.78). Post hoc review of the 6 SRA-positive cases with an adjudicated low PTP demonstrated that their scores would have been increased if the adjudicators had had additional information on heparin exposure prior to ICU admission. In general, the fourth domain of 4Ts (oTher causes of thrombocytopenia) generated the most disagreement. ConclusionsReal-time 4Ts scoring by research coordinators at the time of testing for HIT was not consistent with 4Ts scores obtained by central adjudicators. The results of this comprehensive HIT testing highlight the need for further research to improve the assessment of PTP scoring of HIT for critically ill patients.

Accuracy of Early Prediction of Duration of Mechanical Ventilation by Intensivists

Predictions of duration of mechanical ventilation are frequently made by intensivists and influence clinical decisions. We aimed to measure the accuracy of these clinical early predictions. One hundred fifty-five patients within 48 hours of initiation of mechanical ventilation on a general intensive care unit had clinical data prospectively collected and were followed to determine actual duration of mechanical ventilation. Intensivists, after evaluating patients in the first 2 consecutive days, predicted each duration of mechanical ventilation by selecting between less than 3, 4 to 7, 8 to 14, or more than 14 days. Accuracy of predictions was evaluated by comparisons between predicted and actual durations. Raw agreement (95% confidence interval) between predicted and actual durations, classified into the four categories, was 37% (29-45%). Predictions of duration of more than 7 and more than 14 days showed raw agreements of 59% (51-66%) and 83% (76-88%); sensitivities of 40% (28-54%) and 29% (13-51%); specificities of 71% (61-80%) and 93% (87-97%); positive predictive values of 48% (34-63%) and 44% (20-70%); and negative predictive values of 64% (54-73%) and 87% (81-92%), respectively. The accuracy of intensivists' early clinical predictions of duration of mechanical ventilation is limited, particularly for identifying patients who will require prolonged mechanical ventilation.

Abstract W P328: Comparative Analysis of Two Methods to Score the modified Rankin Scale: Rankin Focused Assessment and Simple modified Rankin Scale Questionnaire

Background: The modified Rankin Scale (mRS) of global disability is the most common primary endpoint in acute stroke clinical trials. Since intuitive scoring of the mRS yields only modest inter-rater reliability, more formal scoring methods, with improved reliability, have recently been developed, but little compared. Methods: The Rankin Focused Assessment (RFA) is a formally operationalized, rater-scoring method using all available data, including patient and caretaker reports, medical records, and direct patient exam. The simple modified Rankin Scale questionnaire is a formally operationalized, patient report-based scoring method. We obtained 3 month mRS scores using the RFA and smRSq in consecutive patients enrolled in the NIH FAST-MAG trial. Results: Among 143 patients assessed at 3 months, the mean age was 66.9 (range 40-89+), 48.2% were female, and stroke subtype was ischemic in 70.6%. Amongst living patients, 3-month assessments were performed in person in 95% and by phone in 5%. With the RFA, mean mRS score was 2.2 and with the smRSq 2.1. The two instruments showed high general rates of agreement amongst all patients: raw percent agreement was 117/143 (84.0%), weighted kappa 0.92 (95% CI 0.89-0.95) and unweighted kappa 0.82 (95% CI 0.75-0.88). Agreement was modestly higher for in person than for phone visits (weighted kappa 0.93 vs 0.77). Of the 26 discrepancies in scoring, 18 (69%) had higher and 8 (31%) lower disability scores with the RFA than with the smRSq. Content analysis of discrepant scores indicated the RFA had greater sensitivity to aspects of disability under-captured by patient self-report. Conclusion: The RFA and the smRSq show excellent convergent validity as tools to score the modified Rankin Scale. The findings of this study suggest that both are useful and have distinct advantages: the smRSq has greater ease of administration due to its brevity and the RFA has greater clinical validity with sensitivity to all sources of disability.

Agreement between telepsychiatry assessment and face-to-face assessment for Emergency Department psychiatry patients

Summary We compared psychiatrists’ evaluations of Emergency Department (ED) mental health patients made face-to-face or by telemedicine. In a 39-month study, 73 patients presenting in the ED were enrolled after initial screening. Patients were interviewed by a psychiatrist either face-to-face in the ED or remotely by video. A second psychiatrist, acting as an observer, was in the room with the patient and independently completed the assessment. Based on the primary diagnosis of the interviewer, 48% of patients had a depressive disorder, 18% a substance use disorder, 14% a bipolar disorder, 11% a psychotic disorder, 6% an anxiety disorder and 4% other disorders. The raw agreement between the psychiatrists about disposition when both used face-to-face assessment was 84% and it was 86% when one used telemedicine. Using Cohen’s kappa to evaluate agreement, there were no significant differences for disposition recommendation, strength of recommendation, diagnosis or the HCR-20 dangerousness scale. There was no significant difference for the intraclass correlation coefficients for the suicide scale. The results provide preliminary support for the safe use of telepsychiatry in the ED to determine the need for admission to inpatient care.

Information needs of early-stage prostate cancer patients: within- and between-group agreement of patients and health professionals

PurposeThe aims of this study were to analyze agreement on information needs within a group of early-state prostate cancer patients and to compare information preferences of patients with the view of health-care professionals about patients’ needs.MethodsSample consists of patients (n = 128) and six subgroups of health-care professionals (urologists, n = 32; nurses, n = 95; radiotherapy technologists (RTTs), n = 36; medical oncologists, n = 19; radiation oncologists, n = 12; general practitioners (GPs), n = 10). Information needs have been assessed with 92 questions concerning prostate cancer and its treatment. Respondents judged the importance of addressing each question. Within- and between-group agreements of patients and health-care professional groups were estimated with raw agreement indices as well as chance-corrected Kappa and Gwet’s AC1 measures. Finally, group-specific core items rated with high importance as well as high agreement were defined.ResultsPatients rated on average (median) half, i.e., 51 out 92 items as essential (interquartile range (IQR) = 36–66), 26 items as desired (IQR = 14–38), and 10 items as avoidable (IQR = 2–22). Within-group agreement on the presented information topics is modest for any participating group (AC1patients = 0.319; AC1professionals = 0.295–0.398). Agreement between patients and professionals is low too (AC1 = 0.282–0.329). Defining group-specific core sets of information topics results in 51 items being part of at least one core set. Concordance of the item core sets of patients and professionals is moderate with κ = 0.38–0.66, sensitivity of professionals’ core sets for patients’ preferences varies between 56 and 74 %.ConclusionsResults emphasize the need for dialogue between doctor/professional and patient in identifying the information needed by individual patients and support the importance of shared decision making.

Reliability of Hip Examination Tests for Femoroacetabular Impingement

To assess the interrater reliability of hip examination tests used to assess femoroacetabular impingement (FAI) among clinicians from different disciplines. Twelve subjects were examined by 9 clinicians using 12 hip tests drawn from a review of the literature and consultation with experts in hip pain and FAI. Examiners assessed both hips of each subject and were blinded to subject history. The order in which subjects were seen, the order of tests, and order of examination of the 2 hips within each subject were all randomized. Interrater reliability (IRR) for the 10 categorical tests was summarized using overall raw agreement (ORA), positive agreement (agreement on abnormal findings), and negative agreement (agreement on normal findings). An ORA of >0.75 was considered to indicate adequate reliability. For the 2 range of motion (ROM) outcomes, IRR was summarized using the median of the absolute difference (MAD) in measurements obtained by any 2 examiners on any patient. MAD reflects the "typical" difference (in degrees) between 2 raters. Adequate reliability (ORA >0.75) was achieved for 6 of the 10 hip examination tests with categorical outcomes. Positive agreement ranged from 0.35 to 0.84, while negative agreement ranged from 0.62 to 0.99. For the ROM outcomes, examiners were, on average, within 5° of each other for flexion and 7° for internal rotation. The results provide evidence that the most common hip examination tests would likely be sufficiently reliable to allow agreement between examiners when discriminating between painful FAI and normal hips in a clinical setting.

Validation of an advanced practice physiotherapy model of care in an orthopaedic outpatient clinic

BackgroundIn Canada, new models of orthopaedic care involving advanced practice physiotherapists (APP) are being implemented. In these new models, aimed at improving the efficiency of care for patients with musculoskeletal disorders, APPs diagnose, triage and conservatively treat patients. Formal validation of the efficiency and appropriateness of these emerging models is scarce. The purpose of this study is to assess the diagnostic agreement of an APP compared to orthopaedic surgeons as well as to assess treatment concordance, healthcare resource use, and patient satisfaction in this new model.Methods120 patients presenting for an initial consult for hip or knee complaints in an outpatient orthopaedic hospital clinic in Montreal, Canada, were independently assessed by an APP and by one of three participating orthopaedic surgeons. Each health care provider independently diagnosed the patients and provided triage recommendations (conservative or surgical management). Proportion of raw agreement and Cohen’s kappa were used to assess inter-rater agreement for diagnosis, triage, treatment recommendations and imaging tests ordered. Chi-Square tests were done in order to compare the type of conservative treatment recommendations made by the APP and the surgeons and Student t-tests to compare patient satisfaction between the two types of care.ResultsThe majority of patients assessed were female (54%), mean age was 54.1 years and 91% consulted for a knee complaint. The raw agreement proportion for diagnosis was 88% and diagnostic inter-rater agreement was very high (κ=0.86; 95% CI: 0.80-0.93). The triage recommendations (conservative or surgical management) raw agreement proportion was found to be 88% and inter-rater agreement for triage recommendation was high (κ=0.77; 95% CI: 0.65-0.88). No differences were found between providers with respect to imaging tests ordered (p≥0.05). In terms of conservative treatment recommendations made, the APP gave significantly more education and prescribed more NSAIDs, joint injections, exercises and supervised physiotherapy (p<0.05). Patient satisfaction was significantly higher for APP care than for the surgeons care (p<0.05).ConclusionThe diagnoses and triage recommendations for patients with hip and knee disorders made by the APP were similar to the orthopaedic surgeons. These results provide evidence supporting the APP model for orthopaedic care.

Point-of-care multiorgan ultrasonography for the evaluation of undifferentiated hypotension in the emergency department

We analyzed the efficacy of a point-of-care ultrasonographic protocol, based on a focused multiorgan examination, for the diagnostic process of symptomatic, non-traumatic hypotensive patients in the emergency department. We prospectively enrolled 108 adult patients complaining of non-traumatic symptomatic hypotension of uncertain etiology. Patients received immediate point-of-care ultrasonography to determine cardiac function and right/left ventricle diameter rate, inferior vena cava diameter and collapsibility, pulmonary congestion, consolidations and sliding, abdominal free fluid and aortic aneurysm, and leg vein thrombosis. The organ-oriented diagnoses were combined to formulate an ultrasonographic hypothesis of the cause of hemodynamic instability. The ultrasonographic diagnosis was then compared with a final clinical diagnosis obtained by agreement of three independent expert physicians who performed a retrospective hospital chart review of each case. Considering the whole population, concordance between the point-of-care ultrasonography diagnosis and the final clinical diagnosis was interpreted as good, with Cohen's k=0.710 (95% CI, 0.614-0.806), p<0.0001 and raw agreement (Ra)=0.768. By eliminating the 13 cases where the final clinical diagnosis was not agreed upon (indefinite), the concordance increased to almost perfect, with k=0.971 (95% CI, 0.932-1.000), p<0.0001 and Ra=0.978. Emergency diagnostic judgments guided by point-of-care multiorgan ultrasonography in patients presenting with undifferentiated hypotension significantly agreed with a final clinical diagnosis obtained by retrospective chart review. The integration of an ultrasonographic multiorgan protocol in the diagnostic process of undifferentiated hypotension has great potential in guiding the first-line therapeutic approach.

Agreement on diagnoses of mental health problems between an online clinical assignment and a routine clinical assignment

We examined the agreement between diagnoses assigned based on the Development and Well Being Assessment (DAWBA) information collected online, and ordinary day-to-day diagnostic assignment by Child and Adolescent Mental Health Service (CAMHS) clinicians. Diagnoses were compared for 286 patients. Raw agreement for diagnostic categories was 74-90%, resulting in kappa values of 0.41-0.49. Multinomial regression models for ‘emotional diagnosis’ and ‘hyperkinetic/conduct diagnosis’ were significant (P < 0.001). Age, gender and number of informants significantly contributed to the explanation of agreement and disagreement. Agreement on mental health diagnoses may be sufficient to replace routine clinical assignment of diagnoses with an online clinical assignment, thereby saving time and resources.