Diagnosis of transient ischemic attacks: improvement of interobserver agreement by a check-list in ordinary language.

Abstract

To try and improve the interobserver agreement for the diagnosis of TIA, we used a checklist in which the symptoms were recorded in plain language, instead of in abstract diagnostic terms such as amaurosis fugax. Criteria for a diagnosis of TIA were similarly phrased and recommended to all observers. Eight senior neurologists and ten neurology residents interviewed 72 patients in random pairs. In 64 cases the observers agreed on the diagnosis (kappa value = 0.77). After a short discussion between the two observers the agreement increased to a maximum (kappa = 1.0). However, in 29 of the 144 interviews the diagnosis would have been different, had the recommended criteria been fully applied. In 28 of these the observer had diagnosed TIA on insufficient evidence. Six "misinterpretations" led to disagreement for the diagnosis and only these were corrected by the observers during their discussion. The present design has led to a maximal agreement for the diagnosis of TIA between two observers, but the agreement between such a pair and the common diagnostic criteria was not yet ideal. The precision of the diagnosis could be improved if details of the required symptoms are discussed in general as well as for each patient.

Predictors of major vascular events in patients with a transient ischemic attack or nondisabling stroke. The Dutch TIA Trial Study Group.

“…For recording the history a checklist on which the possible symptoms were described in plain language 6 was used. The checklist contained a number of detailed multiple-choice questions about the nature as well as the time course of the symptoms, including the mode of onset, synchronicity of the symptoms, duration of the attack, mode of disappearance, and the number of attacks.…”

Interobserver agreement for the assessment of handicap in stroke patients.

“…Second, uniformity might be improved if the observers would use a checklist of activities of daily living as a guide in questioning the patient, as was found the case for the diagnosis of transient ischemic attacks (TIAs). 24 Third, discrepancies between observers are most striking for Grades 2, 3, and 4. This corresponds with the low K for the intermediate level (Grade 3) of the Hunt-Hess scale in the grading of patients with subarachnoid hemorrhage.…”

The Willis lecture: transient ischemic attacks, scientific method, and new realities.

“…Such findings have been verified repeatedly. 49 -50 In an effort to improve agreement, Koudstaal and colleagues 51 devised a questionnaire using patient language rather than medical terms. With a standardized checklist to obtain data, their questionnaire increased agreement between neurologists on classification from 65% to 77% and on vascular distribution from 31% to 65%.…”