Physician agreement on the diagnosis of sepsis in the intensive care unit: estimation of concordance and analysis of underlying factors in a multicenter cohort
Abstract Background Differentiating sepsis from the systemic inflammatory response syndrome (SIRS) in critical care patients is challenging, especially before serious organ damage is evident, and with variable clinical presentations of patients and variable training and experience of attending physi...
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| Format: | Article |
| Language: | English |
| Published: |
BMC
2019-02-01
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| Series: | Journal of Intensive Care |
| Subjects: | |
| Online Access: | http://link.springer.com/article/10.1186/s40560-019-0368-2 |
| _version_ | 1830359219435470848 |
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| author | Bert K. Lopansri Russell R. Miller III John P. Burke Mitchell Levy Steven Opal Richard E. Rothman Franco R. D’Alessio Venkataramana K. Sidhaye Robert Balk Jared A. Greenberg Mark Yoder Gourang P. Patel Emily Gilbert Majid Afshar Jorge P. Parada Greg S. Martin Annette M. Esper Jordan A. Kempker Mangala Narasimhan Adey Tsegaye Stella Hahn Paul Mayo Leo McHugh Antony Rapisarda Dayle Sampson Roslyn A. Brandon Therese A. Seldon Thomas D. Yager Richard B. Brandon |
| author_facet | Bert K. Lopansri Russell R. Miller III John P. Burke Mitchell Levy Steven Opal Richard E. Rothman Franco R. D’Alessio Venkataramana K. Sidhaye Robert Balk Jared A. Greenberg Mark Yoder Gourang P. Patel Emily Gilbert Majid Afshar Jorge P. Parada Greg S. Martin Annette M. Esper Jordan A. Kempker Mangala Narasimhan Adey Tsegaye Stella Hahn Paul Mayo Leo McHugh Antony Rapisarda Dayle Sampson Roslyn A. Brandon Therese A. Seldon Thomas D. Yager Richard B. Brandon |
| author_sort | Bert K. Lopansri |
| collection | DOAJ |
| description | Abstract Background Differentiating sepsis from the systemic inflammatory response syndrome (SIRS) in critical care patients is challenging, especially before serious organ damage is evident, and with variable clinical presentations of patients and variable training and experience of attending physicians. Our objective was to describe and quantify physician agreement in diagnosing SIRS or sepsis in critical care patients as a function of available clinical information, infection site, and hospital setting. Methods We conducted a post hoc analysis of previously collected data from a prospective, observational trial (N = 249 subjects) in intensive care units at seven US hospitals, in which physicians at different stages of patient care were asked to make diagnostic calls of either SIRS, sepsis, or indeterminate, based on varying amounts of available clinical information (clinicaltrials.gov identifier: NCT02127502). The overall percent agreement and the free-marginal, inter-observer agreement statistic kappa (κ free) were used to quantify agreement between evaluators (attending physicians, site investigators, external expert panelists). Logistic regression and machine learning techniques were used to search for significant variables that could explain heterogeneity within the indeterminate and SIRS patient subgroups. Results Free-marginal kappa decreased between the initial impression of the attending physician and (1) the initial impression of the site investigator (κ free 0.68), (2) the consensus discharge diagnosis of the site investigators (κ free 0.62), and (3) the consensus diagnosis of the external expert panel (κ free 0.58). In contrast, agreement was greatest between the consensus discharge impression of site investigators and the consensus diagnosis of the external expert panel (κ free 0.79). When stratified by infection site, κ free for agreement between initial and later diagnoses had a mean value + 0.24 (range − 0.29 to + 0.39) for respiratory infections, compared to + 0.70 (range + 0.42 to + 0.88) for abdominal + urinary + other infections. Bioinformatics analysis failed to clearly resolve the indeterminate diagnoses and also failed to explain why 60% of SIRS patients were treated with antibiotics. Conclusions Considerable uncertainty surrounds the differential clinical diagnosis of sepsis vs. SIRS, especially before organ damage has become highly evident, and for patients presenting with respiratory clinical signs. Our findings underscore the need to provide physicians with accurate, timely diagnostic information in evaluating possible sepsis. |
| first_indexed | 2024-12-20T02:55:39Z |
| format | Article |
| id | doaj.art-58b777a2daf346e396ec3874647a0467 |
| institution | Directory Open Access Journal |
| issn | 2052-0492 |
| language | English |
| last_indexed | 2024-12-20T02:55:39Z |
| publishDate | 2019-02-01 |
| publisher | BMC |
| record_format | Article |
| series | Journal of Intensive Care |
| spelling | doaj.art-58b777a2daf346e396ec3874647a04672022-12-21T19:55:55ZengBMCJournal of Intensive Care2052-04922019-02-017111710.1186/s40560-019-0368-2Physician agreement on the diagnosis of sepsis in the intensive care unit: estimation of concordance and analysis of underlying factors in a multicenter cohortBert K. Lopansri0Russell R. Miller III1John P. Burke2Mitchell Levy3Steven Opal4Richard E. Rothman5Franco R. D’Alessio6Venkataramana K. Sidhaye7Robert Balk8Jared A. Greenberg9Mark Yoder10Gourang P. Patel11Emily Gilbert12Majid Afshar13Jorge P. Parada14Greg S. Martin15Annette M. Esper16Jordan A. Kempker17Mangala Narasimhan18Adey Tsegaye19Stella Hahn20Paul Mayo21Leo McHugh22Antony Rapisarda23Dayle Sampson24Roslyn A. Brandon25Therese A. Seldon26Thomas D. Yager27Richard B. Brandon28Division of Infectious Diseases and Clinical Epidemiology, Intermountain Medical CenterDivision of Pulmonary and Critical Care Medicine, Intermountain Medical CenterDivision of Infectious Diseases and Clinical Epidemiology, Intermountain Medical CenterBrown UniversityBrown UniversityJohns Hopkins University School of MedicineJohns Hopkins University School of MedicineJohns Hopkins University School of MedicineRush Medical College and Rush University Medical CenterRush Medical College and Rush University Medical CenterRush Medical College and Rush University Medical CenterRush Medical College and Rush University Medical CenterLoyola University Medical CenterLoyola University Medical CenterLoyola University Medical CenterGrady Memorial Hospital and Emory University School of MedicineGrady Memorial Hospital and Emory University School of MedicineGrady Memorial Hospital and Emory University School of MedicineNorthwell HealthcareNorthwell HealthcareNorthwell HealthcareNorthwell HealthcareImmunexpress IncImmunexpress IncImmunexpress IncImmunexpress IncImmunexpress IncImmunexpress IncImmunexpress IncAbstract Background Differentiating sepsis from the systemic inflammatory response syndrome (SIRS) in critical care patients is challenging, especially before serious organ damage is evident, and with variable clinical presentations of patients and variable training and experience of attending physicians. Our objective was to describe and quantify physician agreement in diagnosing SIRS or sepsis in critical care patients as a function of available clinical information, infection site, and hospital setting. Methods We conducted a post hoc analysis of previously collected data from a prospective, observational trial (N = 249 subjects) in intensive care units at seven US hospitals, in which physicians at different stages of patient care were asked to make diagnostic calls of either SIRS, sepsis, or indeterminate, based on varying amounts of available clinical information (clinicaltrials.gov identifier: NCT02127502). The overall percent agreement and the free-marginal, inter-observer agreement statistic kappa (κ free) were used to quantify agreement between evaluators (attending physicians, site investigators, external expert panelists). Logistic regression and machine learning techniques were used to search for significant variables that could explain heterogeneity within the indeterminate and SIRS patient subgroups. Results Free-marginal kappa decreased between the initial impression of the attending physician and (1) the initial impression of the site investigator (κ free 0.68), (2) the consensus discharge diagnosis of the site investigators (κ free 0.62), and (3) the consensus diagnosis of the external expert panel (κ free 0.58). In contrast, agreement was greatest between the consensus discharge impression of site investigators and the consensus diagnosis of the external expert panel (κ free 0.79). When stratified by infection site, κ free for agreement between initial and later diagnoses had a mean value + 0.24 (range − 0.29 to + 0.39) for respiratory infections, compared to + 0.70 (range + 0.42 to + 0.88) for abdominal + urinary + other infections. Bioinformatics analysis failed to clearly resolve the indeterminate diagnoses and also failed to explain why 60% of SIRS patients were treated with antibiotics. Conclusions Considerable uncertainty surrounds the differential clinical diagnosis of sepsis vs. SIRS, especially before organ damage has become highly evident, and for patients presenting with respiratory clinical signs. Our findings underscore the need to provide physicians with accurate, timely diagnostic information in evaluating possible sepsis.http://link.springer.com/article/10.1186/s40560-019-0368-2SepsisDiagnosisInter-observer agreementIntensive care |
| spellingShingle | Bert K. Lopansri Russell R. Miller III John P. Burke Mitchell Levy Steven Opal Richard E. Rothman Franco R. D’Alessio Venkataramana K. Sidhaye Robert Balk Jared A. Greenberg Mark Yoder Gourang P. Patel Emily Gilbert Majid Afshar Jorge P. Parada Greg S. Martin Annette M. Esper Jordan A. Kempker Mangala Narasimhan Adey Tsegaye Stella Hahn Paul Mayo Leo McHugh Antony Rapisarda Dayle Sampson Roslyn A. Brandon Therese A. Seldon Thomas D. Yager Richard B. Brandon Physician agreement on the diagnosis of sepsis in the intensive care unit: estimation of concordance and analysis of underlying factors in a multicenter cohort Journal of Intensive Care Sepsis Diagnosis Inter-observer agreement Intensive care |
| title | Physician agreement on the diagnosis of sepsis in the intensive care unit: estimation of concordance and analysis of underlying factors in a multicenter cohort |
| title_full | Physician agreement on the diagnosis of sepsis in the intensive care unit: estimation of concordance and analysis of underlying factors in a multicenter cohort |
| title_fullStr | Physician agreement on the diagnosis of sepsis in the intensive care unit: estimation of concordance and analysis of underlying factors in a multicenter cohort |
| title_full_unstemmed | Physician agreement on the diagnosis of sepsis in the intensive care unit: estimation of concordance and analysis of underlying factors in a multicenter cohort |
| title_short | Physician agreement on the diagnosis of sepsis in the intensive care unit: estimation of concordance and analysis of underlying factors in a multicenter cohort |
| title_sort | physician agreement on the diagnosis of sepsis in the intensive care unit estimation of concordance and analysis of underlying factors in a multicenter cohort |
| topic | Sepsis Diagnosis Inter-observer agreement Intensive care |
| url | http://link.springer.com/article/10.1186/s40560-019-0368-2 |
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