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Interobserver agreement of peritoneal dialysis exit site scoring: Results from the Standardizing Care to Improve
Mahima Keswani1, Kathleen Mallet2, Troy Richardson3
1Division of Pediatric Nephrology, Ann and Robert H. Lurie Children's Hospital, Chicago, IL, USA.
Insights
Interobserver agreement for peritoneal dialysis exit site assessments is high for normal findings but low for abnormalities. Further research is needed to improve agreement and identify infection risk factors.
Area of Science:
- Nephrology
- Infectious Disease
- Medical Device Evaluation
Background:
- Exit site infections are a significant risk factor for peritonitis in patients undergoing long-term peritoneal dialysis.
- Objective characterization of exit site appearance is crucial for monitoring and preventing complications.
- Current visual assessment tools require evaluation for interobserver reliability.
Purpose of the Study:
- To assess the interobserver agreement between two standardized exit site scoring tools.
- To evaluate the reliability of visual assessments in identifying abnormalities in peritoneal dialysis exit sites.
Main Methods:
- Two independent evaluators assessed exit sites during outpatient visits across 13 pediatric end-stage kidney disease sites.
- Paired exit site evaluations were collected over a 6-month period.
- Agreement rates were calculated, with a sub-analysis of disagreements.
Main Results:
- High agreement (78%-97%) was observed when both reviewers found exit sites to be normal.
- Interobserver agreement significantly decreased (31%-66%) when abnormalities were present.
- Disagreements primarily concerned the presence/absence of abnormalities, not their severity.
Conclusions:
- While exit site assessments are reliable for normal findings, significant disagreement exists for abnormal findings.
- Further research is necessary to enhance interobserver agreement in exit site evaluations.
- Identifying specific domains that indicate increased infection risk requires further investigation.
Background:
Exit site infections are a risk factor for the development of peritonitis in patients on long-term peritoneal dialysis. Visual assessments of an exit site utilising currently available tools (Twardowski and Mid-European Pediatric Peritoneal Dialysis Study Group (MEPPS)) are necessary to objectively characterise the appearance of an exit site. The aim of this study was to assess the interobserver agreement of exit site evaluations utilising both exit site scoring tools.
Methods:
Exit site evaluations were independently performed by two evaluators during outpatient visits at 13 sites within the Standardizing Care to Improve Outcomes in Pediatric End Stage Kidney Disease collaborative. The frequency and percentage of evaluations where both reviewers agreed were calculated. A sub-analysis was performed looking at evaluations where disagreement occurred.
Results:
A total of 371 paired exit site evaluations were collected over 6 months. For the majority of evaluations (range: 78%-97% Twardowski, 78%-97% MEPPS), both reviewers agreed that no abnormality was present across all domains. When the analysis was restricted to evaluations where at least one reviewer noted an abnormality, interobserver agreement fell across all domains (range: 31%-61% Twardowski, 56%-66% MEPPS). Disagreements more commonly occurred regarding the presence versus absence of an abnormality, rather than a difference in the severity of an abnormality.
Conclusions:
Whereas interobserver agreement is high when the appearance of a peritoneal dialysis catheter exit site is characterised as 'normal', interobserver disagreement is common when the appearance of the exit site is 'abnormal'. Further work is warranted to improve interobserver agreement of exit site assessments and to identify domains conferring an increased risk of infection.
