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Interobserver agreement in assessment of clinical variables in children with blunt head trauma
Marc H Gorelick1, Shireen M Atabaki, John Hoyle
1Department of Pediatrics, Section of Emergency Medicine, Medical College of Wisconsin, Milwaukee, WI, USA. mgorelic@mcw.edu
Insights
Clinical assessments of children with blunt head trauma show good agreement between observers. These findings support the use of these variables in developing clinical decision rules for pediatric emergency care.
Area of Science:
- Pediatric Emergency Medicine
- Clinical Epidemiology
Background:
- Clinical decision rules require reliable data from historical and physical examinations.
- Interobserver agreement is crucial for validating clinical variables in emergency department (ED) settings.
Purpose of the Study:
- To assess interobserver agreement for historical and physical examination findings in children with blunt head trauma.
- To determine the suitability of these variables for clinical decision rule development.
Main Methods:
- Prospective cohort study of 1500 children with blunt head trauma across 25 EDs in the Pediatric Emergency Care Applied Research Network (PECARN).
- Two independent clinicians completed standardized assessments within 60 minutes of each other, prior to neuroimaging review.
- Interobserver agreement was calculated using kappa statistics; acceptable agreement was defined as a lower 95% confidence limit of kappa > 0.4.
Main Results:
- Acceptable agreement was achieved for 27 of 32 (84%) clinical variables.
- Mechanism of injury assessment showed high agreement (kappa = 0.83).
- Subjective symptoms demonstrated acceptable agreement (kappa range 0.47-0.93), while some physical exam findings, like altered mental status signs, had lower agreement.
Conclusions:
- Most historical and physical examination variables in pediatric blunt head trauma can be reliably assessed by different clinicians.
- These variables demonstrate sufficient interobserver agreement for use in developing clinical decision rules for pediatric emergency care.
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 (kappa) statistic for categorical variables and weighted kappa for ordinal variables. Variables with a lower 95% confidence limit (LCL) of kappa > 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 kappa = 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.
