Interrater reliability of a national acute myocardial infarction register

Quality registry improves the data of chronic ulcers: Validation of Tampere Wound Registry

Quality registries are potential tools for improving health care documentation, but the quality and completeness of each registry should be ensured. This study aimed to evaluate the completion rate (completeness) and accuracy of data, first contact-to-registration time (timeliness), and case coverage of the Tampere Wound Registry (TWR) to assess whether it can be reliably used in clinical practice and for research purposes. Data from all 923 patients registered in the TWR between 5 June 2018 and 31 December 2020 were included in the analysis of data completeness, while data accuracy, timeliness and case coverage were analysed in those registered during the year 2020. In all analyses values over 80% were considered good and values over 90% excellent. The study showed that the overall completeness of the TWR was 81% and overall accuracy was 93%. Timeliness achieved 86% within the first 24 h, and case coverage was found to be 91%. When completion of seven selected variables was compared between TWR and patient medical records, the TWR was found to be more complete in five out of seven variables. In conclusion, the TWR proved to be a reliable tool for health care documentation and an even more reliable data source than patient medical records.

Excellent agreement of Norwegian trauma registry data compared to corresponding data in electronic patient records

BACKGROUND

The Norwegian Trauma Registry (NTR) is designed to monitor and improve the quality and outcome of trauma care delivered by Norwegian trauma hospitals. Patient care is evaluated through specific quality indicators, which are constructed of variables reported to the registry by certified registrars. Having high-quality data recorded in the registry is essential for the validity, trust and use of data. This study aims to perform a data quality check of a subset of core data elements in the registry by assessing agreement between data in the NTR and corresponding data in electronic patient records (EPRs).

METHODS

We validated 49 of the 118 variables registered in the NTR by comparing those with the corresponding ones in electronic patient records for 180 patients with a trauma diagnosis admitted in 2019 at eight public hospitals. Agreement was quantified by calculating observed agreement, Cohen's Kappa and Gwet's first agreement coefficient (AC1) with 95% confidence intervals (CIs) for 27 nominal variables, quadratic weighted Cohen's Kappa and Gwet's second agreement coefficient (AC2) for five ordinal variables. For nine continuous, one date and seven time variables, we calculated intraclass correlation coefficient (ICC).

RESULTS

Almost perfect agreement (AC1 /AC2/ ICC > 0.80) was observed for all examined variables. Nominal and ordinal variables showed Gwet's agreement coefficients ranging from 0.85 (95% CI: 0.79-0.91) to 1.00 (95% CI: 1.00-1.00). For continuous and time variables there were detected high values of intraclass correlation coefficients (ICC) between 0.88 (95% CI: 0.83-0.91) and 1.00 (CI 95%: 1.00-1.00). While missing values in both the NTR and EPRs were in general negligeable, we found a substantial amount of missing registrations for a continuous "Base excess" in the NTR. For some of the time variables missing values both in the NTR and EPRs were high.

CONCLUSION

All tested variables in the Norwegian Trauma Registry displayed excellent agreement with the corresponding variables in electronic patient records. Variables in the registry that showed missing data need further examination.

A Global Overview of Acute Coronary Syndrome Registries: A Systematic Review

The present study was conducted with the aim of identifying, and summarizing the characteristics of ACS registries at national, multinational and international levels. Literature was searched using keywords in the title and/or abstract without any time limit ending in March, 2021. After excluding duplicates, 2 reviewers independently reviewed the titles and/or abstracts and full text for inclusion. Each reviewer independently extracted the characteristics of the registries from included papers. Finally, the extracted characteristics were confirmed by a second reviewer. Out of the 1309 papers included, 71 ACS registries were identified (including 60 national and 11 multinational and international registries). Most national registries were being used in Europe. Most registries focused on measuring quality. In more than half of the registries, all types of ACS patients were enrolled. The diagnostic and drug classification systems were mentioned in eight and five registries, respectively. The design of 55 registries was hospital-based. The ability of computerized audit checks was made for 34 registries. More than half of the registries had patient consent and had a web-based design. In all the ACS registries, patient characteristics, clinical characteristics and treatment characteristics were recorded and post-discharge follow-up information was recorded in 45 registries. In the current situation and given that a limited number of countries in the world have national ACS registries, reviewing the results of this study and modeling the registries implemented in the leading countries can help countries without a registry to design it.

Reliability of estimating left ventricular ejection fraction in clinical routine: a validation study of the SWEDEHEART registry

OBJECTIVE

Patients hospitalized with acute coronary syndrome (ACS) in Sweden routinely undergo an echocardiographic examination with assessment of left ventricular ejection fraction (LVEF). LVEF is a measurement widely used for outcome prediction and treatment guidance. The obtained LVEF is categorized as normal (> 50%) or mildly, moderately, or severely impaired (40-49, 30-39, and < 30%, respectively) and reported to the nationwide registry for ACS (SWEDEHEART). The purpose of this study was to determine the reliability of the reported LVEF values by validating them against an independent re-evaluation of LVEF.

METHODS

A random sample of 130 patients from three hospitals were included. LVEF re-evaluation was performed by two independent reviewers using the modified biplane Simpson method and their mean LVEF was compared to the LVEF reported to SWEDEHEART. Agreement between reported and re-evaluated LVEF was assessed using Gwet's AC2 statistics.

RESULTS

Analysis showed good agreement between reported and re-evaluated LVEF (AC2: 0.76 [95% CI 0.69-0.84]). The LVEF re-evaluations were in agreement with the registry reported LVEF categorization in 86 (66.0%) of the cases. In 33 (25.4%) of the cases the SWEDEHEART-reported LVEF was lower than re-evaluated LVEF. The opposite relation was found in 11 (8.5%) of the cases (p < 0.005).

CONCLUSION

Independent validation of SWEDEHEART-reported LVEF shows an overall good agreement with the re-evaluated LVEF. However, a tendency towards underestimation of LVEF was observed, with the largest discrepancy between re-evaluated LVEF and registry LVEF in subjects with subnormal LV-function in whom the reported assessment of LVEF should be interpreted more cautiously.

Time trends in incidence, treatment, and outcome in acute myocardial infarction in Norway 2013–19

Aims

Acute myocardial infarction (AMI) is a common cause of morbidity and mortality. The aim of the present study was to assess time trends in the incidence, treatment, and outcome of AMI in a nationwide registry–based cohort of patients.

Methods and results

All patients with a first AMI registered in the Norwegian Myocardial Infarction Registry between 2013 and 2019 were included in this cohort study. The number of patients admitted to Norwegian hospitals with a first AMI decreased from 8933 in 2013 to 8383 in 2019. The proportion of patients with ST-elevation myocardial infarction (STEMI) was stable at 30% throughout the period, and the percentage of STEMI undergoing coronary angiography was stable at 87%. The proportion of patients with non-STEMI undergoing coronary angiography increased by 2.4% per year (95% confidence interval 1.6–3.3) from 58% in 2013 to 68% in 2019. More patients were discharged with secondary preventive medication at the end of study period. Age-adjusted 1-year mortality was reduced from 16.4% in 2013 to 15.1% in 2018. The changes over time were primarily seen in the oldest patient groups.

Conclusion

In the period 2013–19 in Norway, we found a reduction in hospitalizations due to a first AMI. Both the percentage of patients undergoing coronary angiography as well as the percentage discharged with recommended secondary preventive therapy increased during the period, and the age-adjusted 1-year mortality after AMI decreased. A national AMI register provides important information about trends in incidence, treatment, and outcome, and may improve adherence to guideline recommendations.

Time trends in adherence to guideline recommendations for anticoagulation therapy in patients with atrial fibrillation and myocardial infarction

BACKGROUND

Poor adherence to guideline recommendations for anticoagulation in patients with acute myocardial infarction (MI) and atrial fibrillation (AF) is previously reported. The aim of the present cohort study was to assess time trends in prescription of anticoagulation therapy in a nationwide registry-based cohort of patients with acute MI and AF.

METHODS

All patients, registered in the Norwegian Myocardial Infarction Registry (NORMI) between 2013 and 2019 with ECG-verified AF at hospitalisation, were included in the cohort study. The primary outcome was the prescription rate of anticoagulation therapy at hospital discharge and follow-up through 2019.

RESULTS

AF was observed in 8565 (10.9% of 78369) patients registered in the NORMI from 2013 through 2019. The congestive heart failure, hypertension, age ≥75 (doubled), diabetes, stroke (doubled), vascular disease, age 65-75, and sex (female) score was ≥2 in 7845 (92%) of the hospitalised patients with AF, and in 7174 (96%) of 7440 patients discharged alive. Only 3704 (47.2%) of these patients were treated with anticoagulation prior to the MI. The prescription rate of anticoagulation therapy at discharge was 55% in 2013, increasing to 78% in 2019 (annual per cent change 6.0 (95% CI 0.7 to 11.6)). Patients prescribed anticoagulation therapy had reduced risk of all types of stroke or death at follow-up compared with patients without prescription of anticoagulation therapy (multivariate-adjusted HR 0.8, 95% CI 0.7 to 0.8, p<0.001).

CONCLUSIONS

The prescription rate of anticoagulation therapy in patients with MI and AF increased during the study period, but many patients were still undertreated with respect to stroke prevention.

A validation study of data in the National Tonsil Surgery Register in Sweden: high agreement with medical records ensures that data can be used to monitor clinical practices and outcomes

BACKGROUND

The ambition of the National Tonsil Surgery Register in Sweden (NTSRS) is to improve otorhinolaryngological care by monitoring trends in the clinical practices, complications, and outcomes of tonsil surgery. The NTSRS collects data from both surgeons and patients and provides the participating clinics with daily updated data on a publicly available website. On the website, national and local results can be compared and monitored. The use of NTSRS data necessitates that the data is valid, but the NTSRS has not yet been validated. With approximately half of the registered patients responding to the postoperative questionnaires, an analysis of responders and non-responders is also necessary. The aim of this study was to assess the criterion validity of NTSRS data. Another aim was to compare the characteristics and rates of complications between postoperative questionnaire responders and non-responders.

METHODS

Data in the NTSRS were compared with data in electronic medical records. The 200 most recent surgeries, up to 31 Dec 2019, in each of 11 surgical units were included. Criterion validity was analysed in terms of observed agreement, Cohens kappa, Gwet's AC₁, and positive and negative agreement. The sign test was used to analyse systematic differences between the NTSRS and the medical records. Comparisons of rates between groups were made with Fisher's exact test, the chi-square test, and Fisher's non-parametric permutation test.

RESULTS

A total of 1991 registrations were included in the study. All variables showed very high observed agreement ranging from 0.91 to 1.00, and all variables had AC₁ values corresponding to almost perfect agreement. The analysis of questionnaire responders and non-responders showed no statistically significant differences regarding age, indication, or type of surgery. The proportion of women was higher in the responder group. The rate of reoperation due to bleeding was higher in the responder group, but there were no differences regarding other complications.

CONCLUSIONS

The results of this study show that data in the NTSRS have criterion validity. The NTSRS is thus well suited for monitoring the clinical practices and outcomes of tonsil surgery. The quality of the data also implies that the registry can be used in both clinical improvement projects and research.

Outcomes after delayed primary percutaneous coronary intervention versus pharmaco-invasive strategy in ST-segment elevation myocardial infarction in Norway

Aims

Primary percutaneous coronary intervention (pPCI) is the preferred reperfusion strategy in patients with ST-segment elevation myocardial infarction (STEMI) provided it can be performed within 120 min from diagnosis. However, it is unclear whether pPCI or a pharmaco-invasive (P-I) strategy is the best choice in patients who cannot receive timely pPCI. The aim of the present study was to compare outcomes after delayed and late pPCI vs. a P-I strategy in STEMI patients who did not receive timely pPCI.

Methods and results

All patients with STEMI registered in the Norwegian Myocardial Infarction Registry (NORMI) between 2013 and 2019, with ≤12 h from symptom onset to first medical contact and available timelines were included in the study. The primary outcome was all-cause mortality, and follow-up was through 2019. A total of 21 121 (27% of 78 368) STEMI patients were registered in the NORMI. Among patients who met the inclusion criteria, 7238 (54%) patients underwent timely pPCI, 1537 (11%) delayed pPCI (121–180 min), 1012 (7%) late pPCI (>180 min), and 2338 (17%) patients were treated with a P-I strategy. After a median follow-up time of 2.5 years, mortality was higher in the delayed pPCI [adjusted hazard ratio (HR) 1.3, 95% confidence interval (CI) 1.0–1.5] and in the late pPCI group (adjusted HR 1.4, 95% CI 1.1–1.7) compared to the P-I strategy group, but bleeding complications were more frequent after P-I strategy.

Conclusions

In STEMI patients who did not receive timely percutaneous coronary intervention, a P-I strategy seemed to be associated with better long-term survival compared to delayed/late pPCI.

Interrater Reliability Across 7 Established Risk Stratification Protocols in Cardiac Rehabilitation

OBJECTIVE

To analyze the interrater agreement among physiotherapists in using 7 risk stratification (RS) protocols to evaluate participants of cardiac rehabilitation (CR) and the main factors associated with disagreements that emerged during the RS process.

DESIGN

Cross-sectional observational study.

SETTING

Outpatient rehabilitation center.

PARTICIPANTS

Patients (N=72) enrolled in CR with a diagnosis of cardiovascular disease or cardiovascular risk factors. Mean age was 65.62±12.14 y, and mean body mass index (calculated as weight in kilograms divided by height in meters squared) was 29.18±4.56.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

The main outcome was to the agreement between 2 physiotherapists in the patients' RS process, using 7 protocols established in the literature for use in CR: American Association of Cardiovascular and Pulmonary Rehabilitation, American College of Sports Medicine, American Heart Association, Sociedade Brasileira de Cardiologia, Sociedad Española de Cardiología, and Société Française de Cardiologie. In addition, the main disagreement factors were assessed.

RESULTS

Interrater agreement was classified as moderate-to-good in the 7 included RS protocols (kappa index between 0.53-0.76). The most important aspects that led to disagreement between physiotherapists were reported in 5 categories. The protocol with the greater agreement index was the American College of Sports Medicine (93.10%; n=67), and the one with the greater disagreement was the American Association of Cardiovascular and Pulmonary Rehabilitation (27.80%; n=20).

CONCLUSIONS

Moderate-to-good interrater agreement among physiotherapists in using 7 RS protocols was observed. Major disagreements were the definition of abnormal hemodynamic responses, rhythm disorders, left ventricular dysfunction, and interpretation of the patient's clinical characteristics.

Incidence, risk factors and outcome of young patients with myocardial infarction

Objective

The decline in the incidence and mortality of acute myocardial infarction (AMI) has been less among younger compared with older individuals. The aim of this nationwide study was to assess the current incidence, risk factors and outcome of AMI in patients <45 years of age.

Methods

All patients ≤80 years of age registered in the Norwegian Myocardial Infarction Register in 2013–2016 were included in this observational, nationwide cohort study. Follow-up was conducted through linkage with the Norwegian Patient Registry through 2017.

Results

Among a total of 33 439 patients ≤80 years with AMI, 1468 (4.4%) were <45 years old. The incidence of AMI was 2.1 per 100 000 person-years in people aged 20–29 years, 16.9 in people aged 30–39 years and 97.6 in people aged 40–49 years. Compared with older patients, patients <45 years were more likely to be male (81%), current smokers (56%), obese (30%) and have a family history of premature AMI (44%), and their low-density lipoprotein-cholesterol levels were higher. Patients <45 years were more likely to have non-obstructive coronary artery disease (14% vs 10%, p<0.001) compared with older patients. During a median follow-up time of 2.4 years, 135 (9%) patients <45 years experienced a new AMI, stroke or death, and 58 (4%) patients died.

Conclusions

The rate of AMI was low in people <45 years old in Norway, but almost one in ten patients with AMI <45 years old died or experienced a new cardiovascular event during follow-up. Increased efforts to improve risk factor control in these patients are warranted.

Poor adherence to guideline recommendations among patients with atrial fibrillation and acute myocardial infarction

Background

The prevalence of atrial fibrillation in patients with acute myocardial infarction is largely unknown. The aims of the present study were to assess the prevalence of atrial fibrillation in a nationwide cohort of patients with acute myocardial infarction, to assess the prescription of anticoagulation therapy, and to study the long-term outcomes.

Design

A nationwide registry-based cohort study.

Methods

All patients registered in the Norwegian Myocardial Infarction Registry between 2013 and 2016 were included and followed up through 2017. Stroke rates during follow-up were obtained through linkage with the Norwegian Patient Registry.

Results

In total, 47,204 patients were registered in the Norwegian Myocardial Infarction Registry. Atrial fibrillation on admission was recorded in 5393 (11%) patients, and 2190 (5%) additional patients developed atrial fibrillation during their hospital stay. Only 45% of patients with atrial fibrillation on admission and CHA2DS2-VASc score ≥ 2 were treated with anticoagulation therapy prior to myocardial infarction, and 56% of patients with atrial fibrillation and CHA2DS2-VASc score ≥ 2 were prescribed anticoagulation therapy at discharge. Patients with myocardial infarction and atrial fibrillation had an increased risk of stroke or death during 822 (426, 1278) days of follow-up compared with patients without atrial fibrillation (multivariate adjusted hazard ratio 1.4, 95% confidence interval 1.3–1.4).

Conclusions

Almost half of patients with atrial fibrillation and myocardial infarction were not prescribed the guideline recommended treatment with anticoagulation therapy at discharge, and their long-term risk of stroke and death was increased compared with patients without atrial fibrillation. Increased efforts to improve the treatment of patients with myocardial infarction and atrial fibrillation are needed.

Unsatisfactory risk factor control and high rate of new cardiovascular events in patients with myocardial infarction and prior coronary artery disease

Background

Patients with established coronary artery disease (CAD) have an increased risk of new cardiovascular events. An underuse of secondary preventive drugs has been observed, and many patients may not attain the treatment goals for secondary prevention. The aims of the present nationwide register-based cohort study were to assess the degree of risk factor control and long-term outcomes in patients < 80 years with Type 1 myocardial infarction (MI) with and without prior CAD.

Methods

Data concerning all patients with MI admitted to hospitals in Norway from 2013 to 2016 were retrieved from the Norwegian Myocardial Infarction Register (NORMI). Long-term mortality was obtained through linkage with the Norwegian Cause of Death Registry.

Results

In total, 47,204 patients were registered in the NORMI from 2013 to 2016. Prior CAD was recorded in 7219 (25.2%) of the 28,607 patients < 80 years old with Type 1 MIs. On average, 3 of the 6 defined treatment targets for secondary preventive therapy were attained, and only 1% of the patients achieved all targets. Patients with MI and prior CAD had increased risk of death or new MI compared to patients without prior CAD during long-term follow-up (adjusted HR 1.6, 95% CI 1.5–1.7).

Conclusions

Prior CAD was frequent in patients with acute MI. The attainment of secondary preventive treatment targets in patients with MI and prior CAD was not optimal, and the long-term outcomes were reduced compared to patients without prior CAD. Increased efforts to improve risk factor control are needed.

BEtablocker Treatment After acute Myocardial Infarction in revascularized patients without reduced left ventricular ejection fraction (BETAMI): Rationale and design of a prospective, randomized, open, blinded end point study

BACKGROUND

Current guidelines on the use of β-blockers in post-acute myocardial infarction (MI) patients without reduced left ventricular ejection fraction (LVEF) are based on studies before the implementation of modern reperfusion and secondary prevention therapies. It remains unknown whether β-blockers will reduce mortality and recurrent MI in contemporary revascularized post-MI patients without reduced LVEF.

DESIGN

BETAMI is a prospective, randomized, open, blinded end point multicenter study in 10,000 MI patients designed to test the superiority of oral β-blocker therapy compared to no β-blocker therapy. Patients with LVEF ≥40% following treatment with percutaneous coronary intervention or thrombolysis and/or no clinical signs of heart failure are eligible to participate. The primary end point is a composite of all-cause mortality or recurrent MI obtained from national registries over a mean follow-up period of 3 years. Safety end points include rates of nonfatal MI, all-cause mortality, ventricular arrhythmias, and hospitalizations for heart failure obtained from hospital medical records 30 days after randomization, and from national registries after 6 and 18 months. Key secondary end points include recurrent MI, heart failure, cardiovascular and all-cause mortality, and clinical outcomes linked to β-blocker therapy including drug adherence, adverse effects, cardiovascular risk factors, psychosocial factors, and health economy. Statistical analyses will be conducted according to the intention-to-treat principle. A prespecified per-protocol analysis (patients truly on β-blockers or not) will also be conducted.

CONCLUSIONS

The results from the BETAMI trial may have the potential of changing current clinical practice for treatment with β-blockers following MI in patients without reduced LVEF. EudraCT number 2018-000590-75.

Providing quality data in health care - almost perfect inter-rater agreement in the Norwegian tonsil surgery register

Background

The Norwegian Tonsil Surgery Register (NTSR) was launched in January 2017. The purpose of the register is to present data on tonsil surgery to facilitate improvements in patient care. Data used for evaluating the quality of medical care needs to be of high reliability. This study aims to assess the inter-rater reliability (IRR) of the variables reported to the register by medical professionals.

Methods

The study population consists of the first 137 tonsil surgery patients who were included in the NTSR at St. Olav’s University Hospital in Trondheim. An experienced rater completed the register’s paper form for all 137 patients based on their electronic medical records, blinded for the data already in the register. To assess the inter-rater reliability between the register and the external rater, we calculated observed agreement, Cohen’s kappa and Gwet’s AC₁ coefficients with 95% confidence intervals.

Results

All tested variables in the NTSR have almost perfect reliability except for the variable for the cold steel technique, which had a substantial to almost perfect reliability. The inter-rater agreement was substantial to almost perfect for every variable, with substantial (kappa/AC₁ > 0.61) to almost perfect (kappa/AC₁ > 0.81) agreement for all the examined variables.

Conclusion

This study shows that the reliability of the NTSR is high for all variables registered by the professionals at the hospital immediately after surgery.

Validation of discharge diagnosis codes to identify serious infections among middle age and older adults

OBJECTIVES

Hospitalisations for serious infections are common among middle age and older adults and frequently used as study outcomes. Yet, few studies have evaluated the performance of diagnosis codes to identify serious infections in this population. We sought to determine the positive predictive value (PPV) of diagnosis codes for identifying hospitalisations due to serious infections among middle age and older adults.

SETTING AND PARTICIPANTS

We identified hospitalisations for possible infection among adults >=50 years enrolled in the Tennessee Medicaid healthcare programme (2008-2012) using International Classifications of Diseases, Ninth Revision diagnosis codes for pneumonia, meningitis/encephalitis, bacteraemia/sepsis, cellulitis/soft-tissue infections, endocarditis, pyelonephritis and septic arthritis/osteomyelitis.

DESIGN

Medical records were systematically obtained from hospitals randomly selected from a stratified sampling framework based on geographical region and hospital discharge volume.

MEASURES

Two trained clinical reviewers used a standardised extraction form to abstract information from medical records. Predefined algorithms served as reference to adjudicate confirmed infection-specific hospitalisations. We calculated the PPV of diagnosis codes using confirmed hospitalisations as reference. Sensitivity analyses determined the robustness of the PPV to definitions that required radiological or microbiological confirmation. We also determined inter-rater reliability between reviewers.

RESULTS

The PPV of diagnosis codes for hospitalisations for infection (n=716) was 90.2% (95% CI 87.8% to 92.2%). The PPV was highest for pneumonia (96.5% (95% CI 93.9% to 98.0%)) and cellulitis (91.1% (95% CI 84.7% to 94.9%)), and lowest for meningitis/encephalitis (50.0% (95% CI 23.7% to 76.3%)). The adjudication reliability was excellent (92.7% agreement; first agreement coefficient: 0.91). The overall PPV was lower when requiring microbiological confirmation (45%) and when requiring radiological confirmation for pneumonia (79%).

CONCLUSIONS

Discharge diagnosis codes have a high PPV for identifying hospitalisations for common, serious infections among middle age and older adults. PPV estimates for rare infections were imprecise.