Chest
Volume 110, Issue 2, August 1996, Pages 343-350
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Clinical Investigations: Infection
Interobserver Reliability of the Chest Radiograph in Community-Acquired Pneumonia

https://doi.org/10.1378/chest.110.2.343Get rights and content

Objective

To evaluate the interobserver reliability of pulmonary radiographic findings in patients with community-acquired pneumonia (CAP).

Design

A prospective, multicenter study.

Setting

Physician offices, medical walk-in clinics, emergency departments, and inpatient wards affiliated with three university hospitals, one community hospital, and one staff model health maintenance organization in three geographic areas.

Methods

Copies of the initial chest radiograph of patients suspected of having CAP were independently read by two staff radiologists at the coordinating university hospital. Interobserver reliability for the interpretation for radiographic findings was assessed by calculation of agreement rates and the kappa statistic.

Participants

Adults (age ≥18 years) with symptoms or signs of CAP and a pulmonary radiographic infiltrate documented by a local study site radiologist.

Results

Among the 282 patients whose initial pulmonary radiographs were evaluated, there was agreement between the two staff radiologists on the presence of infiltrate in 79.4% and on the absence of an infiltrate in 6.0% (kappa=0.37; 95% confidence interval [CI]=0.22 to 0.52). For the 224 patients with an infiltrate identified by both radiologists, there was further agreement that the infiltrate was unilobar in 41.5% and multilobar in 33.9% (kappa=0.51; 95% CI=0.28 to 0.62), pleural effusion was present in 10.7% and absent in 73.2% (kappa=0.46; 95% CI=0.33 to 0.50), and the infiltrate was alveolar in 96.3% of patients and interstitial in no patients (kappa=-0.01; 95% CI=-0.03 to 0.00). Among the 210 patients with an alveolar infiltrate, both radiologists classified the infiltrate as lobar in 74.6% and bronchopneumonia in 2.4% (kappa=0.09; 95% CI=-0.04 to 0.22), and agreed on the presence of air bronchograms in 7.6% and their absence in 52.9% (kappa=0.01; 95% CI=-0.13 to 0.15).

Conclusion

In patients with CAP, two university radiologists identified the presence of infiltrate, multilobar disease, and pleural effusion with fair to good interobserver reliability. However, interobserver reliability for the pattern of infiltrate and the presence of air bronchograms was poor.

Section snippets

MATERIALS AND METHODS

This study of the interobserver reliability of the chest radiograph was conducted as part of the Pneumonia Patient Outcomes Research Team multicenter, prospective cohort study of medical outcomes in ambulatory and hospitalized patients with CAP.15

Patient Characteristics

Table 1 shows the patient characteristics for the 282 patients whose radiographs were reviewed by two radiologists in this study. The mean patient age was 53.7 years (range, 18 to 99 years), and 56.7% were female. In total, 63 (22.3%) radiographs were from patients enrolled in Pittsburgh, 87 (30.9%) from Boston, and 132 (46.8%) from Halifax. More than two thirds of patients (70.2%) were classified as low risk, and more than half (53.2%) were treated in the outpatient setting. Overall, 60% of

DISCUSSION

Detection of an acute radiographic pulmonary infiltrate by a radiologist in an ambulatory patient with acute respiratory symptoms or signs is considered virtually diagnostic of CAP, yet limited information on the interobserver reliability of this radiographic finding exists in patients with this illness. This study demonstrated that among patients with suspected CAP, the interobserver reliability of two university staff radiologists was fair to good for the detection of a pulmonary radiographic

ACKNOWLEDGMENTS

The other investigators in the Pneumonia Patient Outcomes Research Team (PORT) who played an integral role in this investigation were Thomas J. Marrie, MD, Christopher M. Coley, MD, and Daniel E. Singer, MD.

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