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Is the NIHSS certification process too lenient?

Nancy K Hills1, S Andrew Josephson, Patrick D Lyden

  • 1Stroke Sciences Group, Department of Neurology, University of California, San Francisco, CA 94143-0114, USA. nancy.hills@ucsfmedctr.org

Cerebrovascular Diseases (Basel, Switzerland)
|March 20, 2009
PubMed
Summary
This summary is machine-generated.

The National Institutes of Health Stroke Scale (NIHSS) certification test allows multiple correct answers, leading to significant scoring variability among raters. Standardizing scoring could improve consistency in stroke assessments.

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Area of Science:

  • Neurology
  • Clinical Trials
  • Medical Education

Background:

  • The National Institutes of Health Stroke Scale (NIHSS) is crucial for assessing neurological deficits in stroke patients and clinical trials.
  • Inter-rater variability in NIHSS scoring can affect communication and statistical power in research.
  • The NIHSS rater certification process has evolved, with scoring criteria changing over time.

Purpose of the Study:

  • To examine the range of possible total NIHSS scores based on answers provided during rater certification tests.
  • To assess the impact of scoring variability on the reliability of the NIHSS.

Main Methods:

  • Analysis of certification test results from over 7,000 raters between 1998 and 2004.
  • Determination of score ranges using the National Stroke Association (NSA) answer key for each patient.
  • Examination of score distributions among raters who passed the certification test.

Main Results:

  • A single patient's NIHSS score could have between 2 and 12 different correct total scores based on the NSA key.
  • Among certified raters, score distributions were wider, with one patient receiving 18 different correct total scores.
  • The flexibility in acceptable answers contributes to significant scoring variability.

Conclusions:

  • Allowing multiple acceptable answers in NIHSS certification introduces scoring variability.
  • Wider ranges of acceptable answers likely correlate with greater variability in clinical practice and trials.
  • Achieving greater consistency may require expert consensus on 'best' answers and interactive training modules.