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Magnitude and consequences of error in coronary angiography interpretation (the ACRE study)
S Banerjee1, A M Crook, J R Dawson
1Royal Hospitals Trust, St. Bartholomew's and the London Chest Hospitals, United Kingdom.
Insights
Interobserver variability in interpreting coronary angiograms shows good agreement on the number of narrowed arteries. However, disagreements in patient management decisions can arise independently of interpretation errors.
Area of Science:
- Cardiology
- Medical Imaging
- Clinical Research
Background:
- Interobserver variability in coronary angiogram interpretation lacks contemporary data.
- Assessing agreement beyond chance is crucial for understanding diagnostic reliability.
Purpose of the Study:
- To quantify interobserver variability in interpreting the number of narrowed arteries from coronary angiograms.
- To evaluate agreement between actual patient management and cardiologists' recommendations.
Main Methods:
- Two hundred nine coronary angiograms were reviewed by two independent cardiologists.
- Agreement was assessed for the number of narrowed arteries (using Coronary Artery Surgery Study criteria) and patient management decisions.
- Statistical analysis included weighted kappa statistics.
Main Results:
- Cardiologists agreed with the angiographic report on the number of narrowed arteries in 59-60% of cases (weighted kappa = 0.63-0.64).
- Agreement on patient management between actual procedures and recommendations was 72-74% (kappa = 0.46-0.48).
- Management agreement improved when analysis focused on cases with unanimous interpretation agreement.
Conclusions:
- Good agreement exists among cardiologists in interpreting the number of narrowed arteries on coronary angiograms.
- Discrepancies in patient management decisions stem from both interpretation errors and independent factors.
- Improving diagnostic accuracy and standardizing interpretation criteria may enhance patient care consistency.
Abstract:
In the routine reporting of coronary angiograms, there are no contemporary estimates of the magnitude and consequences of interobserver variability. We therefore measured the agreement beyond chance between (1) the number of narrowed arteries on an angiographic report extracted from case notes and independent assessments by 2 cardiologists, and (2) actual patient management over an 18-month follow-up period and each cardiologist's hypothetical management proposal based on abstracted clinical details. Two hundred nine angiograms were randomly selected from 4,121 patients in a prospective study (Appropriateness of Coronary Revascularisation [ACRE study]). The number of narrowed arteries was defined using Coronary Artery Surgery Study (CASS) criteria. For the number of narrowed arteries, cardiologists A and B agreed with the angiographic report in 126 patients (60%, weighted kappa = 0.64) and 124 patients (59%, weighted kappa = 0.63), respectively. In a subset of 92 patients (44%) there was unanimous agreement on the number of narrowed arteries (both cardiologists agreed with the angiographic report). Comparing actual management (34 percutaneous transluminal coronary angioplasty and 39 coronary artery bypass grafting procedures on follow-up) with each of the cardiologist's management recommendations showed agreement in 150 patients (72%, kappa = 0.46) and 154 patients (74%, kappa = 0.48) for cardiologists A and B, respectively. These agreements on management improved (p = 0.05) for cardiologist B (but not A) when analysis was confined to the subset of 92 patients, showing agreement in 73 patients (79%, kappa = 0.60). Thus, in routine clinical practice, the agreement beyond chance in interpretation of the number of narrowed arteries was good. Disagreements on subsequent patient management arose as a result of, and independent of, errors in angiographic interpretation.