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Inter-radiologist agreement for CT scoring of pediatric splenic injuries and effect on an established clinical
Insights
Radiologist agreement on pediatric spleen injury grading impacts patient care. Disagreements in CT scoring can alter intensive care decisions, hospital stays, and return to activity for children with spleen injuries.
Area of Science:
- Pediatric Surgery
- Radiology
- Trauma Management
Background:
- The American Pediatric Surgical Association (APSA) recommends clinical practice guidelines for pediatric spleen injuries.
- These guidelines rely on the American Association for the Surgery of Trauma (AAST) CT scoring system for spleen injury grading.
Purpose of the Study:
- To assess the impact of radiologist agreement on CT scoring of pediatric spleen injuries.
- To evaluate how inter-rater variability in AAST grading affects an established APSA clinical practice guideline.
Main Methods:
- Retrospective analysis of 90 pediatric blunt splenic injuries from 2007-2012.
- Four radiologists reviewed CT scans, grading injuries using the AAST system and identifying extravasation/pseudoaneurysm.
- Inter-rater agreement was measured using Fleiss kappa, Kendall coefficient, and weighted/prevalence-adjusted kappa statistics.
Main Results:
- Good inter-rater agreement for absolute AAST injury grade (kappa: 0.64) and excellent for relative grade (Kendall w: 0.90).
- Complete agreement on AAST grade occurred in only 52% of cases.
- Disagreements could have altered intensive care management (11%), length of hospital stay (44%), and return to normal activity (44%).
Conclusions:
- Radiologist agreement in assigning splenic AAST injury grades is imperfect.
- Disagreements in CT grading can significantly influence management decisions for pediatric spleen injuries.
Background:
The American Pediatric Surgical Association (APSA) advocates for the use of a clinical practice guideline to direct management of hemodynamically stable pediatric spleen injuries. The clinical practice guideline is based on the CT score of the spleen injury according to the American Association for the Surgery of Trauma (AAST) CT scoring system.
Objective:
To determine the potential effect of radiologist agreement for CT scoring of pediatric spleen injuries on an established APSA clinical practice guideline.
Materials And Methods:
We retrospectively analyzed blunt splenic injuries occurring in children from January 2007 to January 2012 at a single level 1 trauma center (n = 90). Abdominal CT exams performed at clinical presentation were reviewed by four radiologists who documented the following: (1) splenic injury grade (AAST system), (2) arterial extravasation and (3) pseudoaneurysm. Inter-rater agreement for AAST injury grade was assessed using the multi-rater Fleiss kappa and Kendall coefficient of concordance. Inter-rater agreement was assessed using weighted (AAST injury grade) or prevalence-adjusted bias-adjusted (binary measures) kappa statistics; 95% confidence intervals were calculated. We evaluated the hypothetical effect of radiologist disagreement on an established APSA clinical practice guideline.
Results:
Inter-rater agreement was good for absolute AAST injury grade (kappa: 0.64 [0.59–0.69]) and excellent for relative AAST injury grade (Kendall w: 0.90). All radiologists agreed on the AAST grade in 52% of cases. Based on an established clinical practice guideline, radiologist disagreement could have changed the decision for intensive care management in 11% (10/90) of children, changed the length of hospital stay in 44% (40/90), and changed the time to return to normal activity in 44% (40/90).
Conclusion:
Radiologist agreement when assigning splenic AAST injury grades is less than perfect, and disagreements have the potential to change management in a substantial number of pediatric patients.
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