Does the Patient Appear Acutely or Chronically Ill?

Physicians' Outcome Predictions for Elderly Patients: Survival, Hospital Discharge, and Length of Stay in a Department of Internal Medicine

In order to study physicians' ability to predict survival, site of living after discharge, and length of stay in a hospital department of internal medicine, five physicians rated a total of 156 patients 65 years of age and older, who had been admitted due to acute illness. Predicted and observed outcome were compared. The results showed no relation except with regard to predicted and observed discharge to own home. Inter-rater reliability was found to be low except with regard to discharge to own home. This study shows that the physicians had difficulties in predicting survival or death in the ward, site of living after discharge, other than to own home, and length of stay in the ward. In order to increase the knowledge about elderly with acute illness and improve planning of individual care, it is desirable to develop reliable and valid instruments for clinical prediction of outcome for elderly persons in short-term hospital care.

Is "appearing chronically ill" a sign of poor health? A study of diagnostic accuracy

Objective

To determine the sensitivity and specificity of a physician’s assessment that a patient “appears chronically ill” for the detection of poor health status.

Methods

The health status of 126 adult outpatients was determined using the 12-Item Short Form Health Survey (SF-12). Physician participants (n = 111 residents and faculty) viewed photographs of each patient participant and assessed whether or not the patient appeared chronically ill. For the entire group of physicians, the median sensitivity and specificity of “appearing chronically ill” for the detection of poor health status (defined as SF-12 physical health score below age group norms by at least 1 SD) were calculated. The study took place from February 2009 to January 2011.

Results

Forty-two participants (33%) had an SF-12 physical health score ≥1 SD below age group norms, and 22 (18%) had a score ≥2 SD below age group norms. When poor health status was defined as an SF-12 physical score ≥1 SD below age group norms, the median sensitivity was 38.1% (IQR 28.6–47.6%), specificity 78.6% (IQR 69.0–84.0%), positive likelihood ratio 1.64 (IQR 1.42–2.15), and negative likelihood ratio 0.82 (IQR 0.74–0.87). For an SF-12 physical score ≥2 SD below age group norms, the median sensitivity was 45.5% (IQR 36.4–54.5%), specificity 76.9% (IQR 66.3–83.7%), positive likelihood ratio 1.77 (IQR 1.49–2.25), and negative likelihood ratio 0.75 (IQR 0.66–0.86).

Conclusions

Our study suggests that a physician’s assessment that a patient “appears chronically ill” has poor sensitivity and modest specificity for the detection of poor health status in adult outpatients. The associated likelihood ratios indicate that this assessment may have limited diagnostic value.

Evaluation of the physician's ability to recognize the presence or absence of anemia, fever, and jaundice

OBJECTIVE

The evaluation of the patient through a comprehensive history and physical examination is considered the cornerstone of medical diagnosis, but many studies suggest that physicians have inadequate physical examination skills. It is unknown whether these skills are reliable and whether they can be adequately acquired through training. The objective of this study was to evaluate the ability of the clinician to detect the presence and discriminate the extent of clinical anemia, fever, and jaundice in an ED or hospitalized patient.

METHODS

This was a prospective observational study of a convenience sample of patients presenting to the ED or admitted to the hospital who had a rectal temperature measurement within 30 minutes prior to the observation, serum hematocrit measurement on the day of observation, or serum bilirubin measurement one day prior to the day of observation. Observers' (emergency medicine attending physicians', resident physicians', and rotating medical students') estimated serum hematocrit, rectal temperature, and serum bilirubin values were obtained after each observation. Sensitivity, specificity, positive predictive value, negative predictive value, and mean absolute difference between actual and estimated values were calculated for each observer.

RESULTS

The physicians detected the presence or absence of anemia, fever, and jaundice in patients with sensitivities and specificities of approximately 70%. Their predictions varied from the measured value on average by 6.0 +/- 4.6% for serum hematocrit, 1.3 + 1.1 degrees F for rectal temperature, and 3.4 +/- 5.3 mg/dL for serum bilirubin. Observer accuracy decreased when evaluating patients with high and low measured values.

CONCLUSIONS

The ability to correctly perform and interpret the physical examination appears to be independent of the observer level of training, patient ethnicity, or patient gender. The examination for pallor, warmth, and jaundice is unreliable in predicting the corresponding laboratory or electronic measurement. Certain anemic, febrile, or jaundiced patients may not be reliably detected solely by a focused physical examination.

Interobserver variations in assessment of antral disease from direct sinoscopic observations compared to video recordings

We tested the reliability of visual clinical sinoscopic observations by using video recordings. An edited video tape was made from the video-recorded bilateral antral sinoscopies of nine patients included in a prospective case series of inflammatory maxillary sinus disease in critically ill patients. An expert panel of four consultant ENT surgeons made individual appraisals of the video using a structured form. They had only been informed in general about the study, but had no further case knowledge in order to avoid all biases. Concordance and interobserver variabilities in the expert panel were compared in pairs. The assessments of the expert panel were compared with the observations of the performer, who was biased through individual case knowledge. Nine patients, either nasotracheally intubated or tracheotomized, had ventilator treatment for more than 7 days. One ENT surgeon performed all sinoscopies and made the direct observations. Satisfactory agreement was found on mucosal alterations. The concordance of recognizing bacterial infection was almost perfect. However, the assessment of redness from a video recording displayed only chance agreement. The differences between kappa statistic values within the expert panel group compared to the comparisons of performer versus expert panel were not significant. The case knowledge of the sinoscopist did not alter the assessments markedly and thus seemed only to have minor influence. Video recording as a method for second opinion was shown to be a useful technique, but will have to be further developed.

Interobserver variation in the evaluation of neurological signs: observer dependent factors

Interobserver variation among four observers in evaluation of eight selected neurological signs was investigated. MATERIAL & METHODS--Two hundred and two consecutive unselected inpatients were examined by two senior neurologists and two trainees, all without knowledge of the neurological case history. The signs examined were: anisocoria, jerky eye movements, facial palsy, elbow extension force, finger-nose test, Barré sign, knee jerk, and extensor plantar reflex. Observed agreement rates and kappa coefficients were calculated in order to compare the interobserver variability among neurologists and trainees, and to evaluate differences in the interobserver variability between signs. RESULTS--Observed agreement rates varied from 0.80 to 0.95 for neurologists and from 0.65 to 0.98 for trainees. For neurologists kappa coefficients ranged from 0.40 to 0.67 and for trainees from 0.22 to 0.81. The neurologists had higher kappa values than the trainees in 5 signs, but this difference was only statistically significant for jerky eye movements. For the individual signs the observed agreement rates were between 0.50 and 0.93 for all four examiners combined, and overall kappa values varied from 0.32 to 0.71 with highest agreement for facial palsy and lowest for knee jerk. CONCLUSION--The magnitude of the interobserver and intersign variation indicates that the interpretation of the neurological signs tested, without knowledge of the case history, should be done with some caution.

A new method of estimation of interobserver variation and its application to the radiological assessment of osteoarthrosis in hip joints

Four frequently referenced radiological methods for assessment of osteoarthrosis in hip joints are compared with respect to their interobserver variation. One hundred hip joints were rated by four observers. Each observer applied all four methods to all the radiographs. The results were analysed by a new statistical method, which allowed detailed assessment of the nature and extent of interobserver variation. Significant differences in terms of intraobserver disagreement were found, and Heripret's method was the best in this respect. All four methods showed a significant degree of systematic disagreement among the observers. This suggests that the interobserver variation might be reduced by confronting the observers with the results of the statistical analysis of their judgements.

Observer variability in assessment of angiographic vasospasm after aneurysmal subarachnoid haemorrhage

In clinical practice and in many reported studies about incidences and time courses of vasospasm the angiographic spasms are judged by eye without clear definition of vessel narrowings. To evaluate the reliability of this diagnostic method two experienced neuroradiologists and two experienced neurosurgeons independently in two sessions, examined 30 carotid angiograms performed after an aneurysmal subarachnoid haemorrhage. The intra- and inter-observer agreements for the absent/present and localization diagnosis of vasospasm were calculated by means of Kappa statistics. Kappa values for both intra- and inter-observer agreement showed great variability and in general most of the agreements were not much better than chance expected agreement. The diagnostic method of judging angiographic vasospasm by eye without clear-cut definitions of vessels narrowings is unreliable and should not be used in the future, neither in clinical practice nor in research.

Interobserver variation in the detection of metastases on liver scans

Two specialists in nuclear medicine and two trainees independently read 106 liver scans for abnormalities suggestive of metastases. The four observers made a positive diagnosis with a significantly different frequency. The overall agreement between pairs of observers was 0.83-0.87. After adjusting for the expected chance agreement, kappa-values between 0.66 and 0.74 were obtained. No difference was found in the level of agreement between the two specialists or between the two trainees. After a consensus conference where the observers tried to unify their diagnostic interpretation, another 106 scans were read for abnormalities suggestive of metastases. The conference did not increase the level of agreement. Scintigraphic lesions that especially imply a risk of disagreement are pointed out.