Interrater Reliability of Criteria Used in Assessing Blunt Head Injury Patients for Intracranial Injuries

Hollander, Judd E.; Go, Steven; Lowery, Douglas W.; Wolfson, Allan B.; Pollack, Charles V.; Herbert, Mel; Mower, William R.; Hoffman, Jerome R.

doi:10.1111/j.1553-2712.2003.tb00624.x

Cited by 12 publications

(4 citation statements)

References 12 publications

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“…The κ statistics for agreement between blinded and unblinded reviews were 0.80 for chest pain, 0.85 for heart failure, 0.86 for coronary revascularization and 0.74 for myocardial infarction (Table 2). Thus, the agreement between the blinded and unblinded reviews was in the good to excellent range for all outcomes [17, 18]. The standard errors for these κ statistics were near 0.06 for all, and p-values were all < 0.0001 (Table 2).…”

Section: Resultsmentioning

confidence: 92%

Cardiovascular outcome ascertainment was similar using blinded and unblinded adjudicators in a national prospective study

Parmar

Ghuge

Halanych

et al. 2010

Journal of Clinical Epidemiology

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OBJECTIVE Observational studies can avoid biases by blinding medical records to characteristics of interest prior to outcomes adjudication. However, blinding is costly. We assessed the effect of blinding race and geography on outcomes ascertainment. STUDY DESIGN AND SETTING The REasons for Geographic And Racial Differences in Stroke-Myocardial Infarction (REGARDS-MI) Study is an ancillary study to the REGARDS national prospective cohort study including 30,228 participants. The primary characteristics of interest are race and geography, and the prespecified acceptable agreement rate between adjudicators is set at > 80%. We selected 116 suspected cardiovascular events that underwent adjudication with usual blinding. At least 3 months later, cases were readjudicated without blinding race and geographic location of the patient. We assessed differences in outcomes ascertainment using Cohen s κ statistic and agreement rates. RESULTS Agreement between the blinded and unblinded reviews was good to excellent for all four outcomes. κ statistics were 0.80 (chest pain), 0.85 (heart failure), 0.86 (revascularization) and 0.74 (MI) (p<0.0001 for all). Within each outcome, agreement rates were similar for race and geographic groups (agreement 83–100%). CONCLUSION In observational studies, blinding medical record review for outcomes ascertainment for some types of patient characteristics may be an unwarranted expense.

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Section: Resultsmentioning

confidence: 92%

Cardiovascular outcome ascertainment was similar using blinded and unblinded adjudicators in a national prospective study

Parmar

Ghuge

Halanych

et al. 2010

Journal of Clinical Epidemiology

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“…Altered mental status, specifically as assessed by the GCS and other rating scales, has been most extensively studied, although much of the published work is in adult patients, 16,17 or in patients with conditions other than acute head injury. 18,19 In a study of children with minor head injury (defined as at nine Canadian pediatric teaching hospitals, Osmond et al 20 found moderate agreement in initial GCS, with j = 0.54.…”

Section: Discussionmentioning

confidence: 99%

Interobserver Agreement in Assessment of Clinical Variables in Children with Blunt Head Trauma

Gorelick

Atabaki

Hoyle

et al. 2008

Academic Emergency Medicine

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Objectives: To be useful in development of clinical decision rules, clinical variables must demonstrate acceptable agreement when assessed by different observers. The objective was to determine the interobserver agreement in the assessment of historical and physical examination findings of children undergoing emergency department (ED) evaluation for blunt head trauma.Methods: This was a prospective cohort study of children younger than 18 years evaluated for blunt head trauma at one of 25 EDs in the Pediatric Emergency Care Applied Research Network (PECARN). Patients were excluded if injury occurred more than 24 hours prior to evaluation, if neuroimaging was obtained at another hospital prior to evaluation, or if the patient had a clinically trivial mechanism of injury. Two clinicians independently completed a standardized clinical assessment on a templated data form. Assessments were performed within 60 minutes of each other and prior to clinician review of any neuroimaging (if obtained). Agreement between the two observers beyond that expected by chance was calculated for each clinical variable, using the kappa (j) statistic for categorical variables and weighted kappa for ordinal variables. Variables with a lower 95% confidence limit (LCL) of j > 0.4 were considered to have acceptable agreement.Results: Fifteen-hundred pairs of observations were obtained. Acceptable agreement was achieved in 27 of the 32 variables studied (84%). Mechanism of injury (low, medium, or high risk) had j = 0.83. For subjective symptoms, kappa ranged from 0.47 (dizziness) to 0.93 (frequency of vomiting); all had 95% LCL > 0.4. Of the physical examination findings, kappa ranged from 0.22 (agitated) to 0.89 (Glasgow Coma Scale [GCS] score). The 95% LCL for kappa was <0.4 for four individual signs of altered mental status and for quality (i.e., boggy or firm) of scalp hematoma if present.Conclusions: Both subjective and objective clinical variables in children with blunt head trauma can be assessed by different observers with acceptable agreement, making these variables suitable candidates for clinical decision rules.

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“…All 7 criteria are basic elements of a history and physical examination and have demonstrated high interrater reliability. 31 Although the test characteristics of the decision aid suggest that it could be useful in clinical practice, it is important to note that this is a derivation study only and must be validated in a separate cohort before it can be recommended for widespread adoption. In addition, among the subset of patients who were younger than 3 years, for whom the sample size is small, the CIs for sensitivity and NPV are wide, making additional prospective validation in a larger cohort even more crucial.…”

Section: Discussionmentioning

confidence: 99%

“…26,27 These candidate variables were chosen by consensus of the study investigators because they had been described as possibly being predictive of ICI in previous literature,* and each of them was shown during the derivation study to exhibit a high level of raw agreement, as well as a Ͼ 0.50. 31 The optimum decision instrument derived for the entire study cohort of 13 728 patients is composed of the following 8 variables: evidence of significant skull fracture, altered level of alertness, neurologic deficit, persistent vomiting, presence of scalp hematoma, abnormal behavior, coagulopathy, and age Ͼ65 years. 26 This instrument had a sensitivity of 98.3% (95% CI: 97.2-99.0) and a specificity of 13.7% (95% CI: 13.1-14.3) in all study patients.…”

Section: Methodsmentioning

confidence: 99%

Performance of a Decision Rule to Predict Need for Computed Tomography Among Children With Blunt Head Trauma

Oman

Cooper

Holmes³

et al. 2006

Pediatrics

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109

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OBJECTIVE. To assess the ability of the NEXUS II head trauma decision instrument to identify patients with clinically important intracranial injury (ICI) from among children with blunt head trauma.METHODS. An analysis was conducted of the pediatric cohort involved in the derivation set of National Emergency X-Radiography Utilization Study II (NEXUS II), a prospective, observational, multicenter study of all patients who had blunt head trauma and underwent cranial computed tomography (CT) imaging at 1 of 21 emergency departments. We determined the test performance characteristics of the 8-variable NEXUS II decision instrument, derived from the entire NEXUS II cohort, in the pediatric cohort (0 -18 years of age), as well as in the very young children (Ͻ3 years). Clinically important ICI was defined as ICI that required neurosurgical intervention (craniotomy, intracranial pressure monitoring, or mechanical ventilation) or was likely to be associated with significant long-term neurologic impairment.RESULTS. NEXUS II enrolled 1666 children, 138 (8.3%) of whom had clinically important ICI. The decision instrument correctly identified 136 of the 138 cases and classified 230 as low risk. A total of 309 children were younger than 3 years, among whom 25 had ICI. The decision instrument identified all 25 cases of clinically important ICI in this subgroup.CONCLUSIONS. The decision instrument derived in the large NEXUS II cohort performed with similarly high sensitivity among the subgroup of children who were included in this study. Clinically important ICI were rare in children who did not exhibit at least 1 of the NEXUS II risk criteria. a common cause of emergency-department (ED) presentation, accounting for ϳ1 million visits annually. 1 Although the majority of patients with head trauma have a minor injury that requires no specific therapy, a small number prove to have clinically significant intracranial injury (ICI). Because of the risk of unrecognized ICI, clinicians liberally order cranial computed tomography (CT) in blunt trauma, generating annual charges of nearly $750 million while revealing significant ICI in Ͻ60 000 patients. [2][3][4] The overuse of CT may be even more pronounced in children, who comprise almost 40% of these patients, 5 because of the greater difficulty in assessing neurologic function in at least some of them.A number of investigators have attempted to identify clinical criteria that accurately predict which patients are at risk for ICI and thus limit CT imaging to such patients. Although these reports provide some preliminary evidence, limitations in study design, including retrospective chart review, small sample size, and restricted age or selection criteria, limit the strength of any of these instruments. [7][8][9][10][11][13][14][15][18][19][20][21][22][23][24][25] The National Emergency X-Radiography Utilization Study II (NEXUS II) is an ongoing, prospective, multicenter study of blunt head trauma victims that was designed to derive and subsequently validate a decision aid to ide...

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Interrater Reliability of Criteria Used in Assessing Blunt Head Injury Patients for Intracranial Injuries

Abstract: The clinicians in our study had a substantial level of agreement regarding most clinical criteria assessed in this large sample of patients with blunt head injury.

Cited by 12 publications

References 12 publications

Cardiovascular outcome ascertainment was similar using blinded and unblinded adjudicators in a national prospective study

Cardiovascular outcome ascertainment was similar using blinded and unblinded adjudicators in a national prospective study

Interobserver Agreement in Assessment of Clinical Variables in Children with Blunt Head Trauma

Performance of a Decision Rule to Predict Need for Computed Tomography Among Children With Blunt Head Trauma

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