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Division of Cerebrovascular Diseases, Department of Neurology (Drs. Gordon, Bendixen, Adams, and Kappelle), and Division of Biostatistics, Department of Preventive Medicine (Drs. Clarke and Woolson), University of Iowa College of Medicine, Iowa City, IA.
To test interphysician agreement on the diagnosis of subtype of ischemic stroke, we sent subtype definitions and 18 case summaries (clinical features and pertinent laboratory data) to 24 neurologists who have a special interest in stroke, and asked them to determine the most likely subtype diagnosis. The overall agreement was 0.64 (Kappa [K]=0.54). Interphysician agreement was highest for the diagnoses of stroke secondary to cardioembolism (K=0.75) or to large-artery atherosclerosis (K=0.69). Individual physicians varied widely; four agreed with the consensus diagnosis in all 18 cases, while six others disagreed with the consensus diagnosis in three to five cases. Our level of interphysician agreement is greater than that reported in other studies and was substantial. However, despite using subtype definitions and being given extensive information often not available in the acute setting, physicians still disagree about the etiology of stroke, particularly in regard to stroke due to small-artery occlusion or of undetermined etiology. Physicians seem reluctant not to attribute stroke to a specific etiology. The uncertainty about subtype diagnosis will affect interpretation of the results of clinical trials in patients selected by the subtype of ischemic stroke and also suggests that results of treatment as affected by subtype should be cautiously interpreted unless efforts to assure uniformity are included in the trial's operations. Refinement of algorithms for determining subtype of ischemic stroke do improve interphysician agreement. Such criteria should be applied strictly, and trials should include measures to assure the most uniform diagnosis of stroke subtype possible.
Address correspondence and reprint requests to Dr. Harold P. Adams, Jr., Division of Cerebrovascular Diseases, Department of Neurology, University of Iowa, 200 Hawkins Drive, Iowa City, IA 52242-1053.
Supported by grants NIH-NINDS-RO1-NS27863 and NIH-NINDS-RO1-NS27960.
Received July 20, 1992. Accepted for publication in final form September 4, 1992.
This paper has been approved by the TOAST Study Group Publications Committee.
Presented in part at the 43rd annual meeting of the American Academy of Neurology, Boston, MA, April 1991.
*TOAST centers and investigators are listed in the Appendix.
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