title: Inter-observer variability in APACHE II scoring: effect of strict guidelines and training.
abstract: OBJECTIVE
  To assess the effect of strict guidelines and a rigorous training program on variability in scoring the revised Acute Physiology and Chronic Health Evaluation (APACHE II).
  
  
  METHODS
  Prospective survey and intervention in the surgical ICU of a university teaching hospital.
  
  
  METHODS
  Seven experienced intensivists and nine residents determined APACHE II scores in one set of patients before and in another set 4 months after a rigorous training program, following strict guidelines for using the APACHE II.
  
  
  RESULTS
  APACHE II scores were 14.3+/-4.4 before the training program (n=12) and 18.9+/-2.4 after (n=11). Interobserver agreement rates increased significantly from 59.7% to 76.5% and the interobserver reliability coefficient (weighted kappa) from 0.72 to 0.85 after our training program was implemented. The changes were significantly greater in experienced intensivists than in less experienced residents, indicating that more experienced physicians profited to a greater degree from our training program.
  
  
  CONCLUSIONS
  Interobserver variability in APACHE II scoring decreases markedly when strict guidelines and a regular training program are implemented, particularly among more experienced physicians. However, in our study a degree of variability (10-15%) persisted even in experienced intensivists with similar training, experience, and background, suggesting that a degree of variability is inherent in APACHE II scoring.
authors.affiliation: Surgical Intensive Care Unit, University Hospital Vrije Universiteit, P.O. Box 7057, 1007 MB Amsterdam, The Netherlands. k.polderman@azvu.nl
authors.forename: K H
authors.initials: KH
authors.lastname: Polderman
authors.forename: E M
authors.initials: EM
authors.lastname: Jorna
authors.forename: A R
authors.initials: AR
authors.lastname: Girbes
mesh_terms: D018806:APACHE; D002983:Clinical Competence; D004501:Education, Medical; D006801:Humans; D007318:Inservice Training; D007362:Intensive Care Units; D007396:Internship and Residency; D019300:Medical Errors / Q000517:prevention & control; D009426:Netherlands; D015588:Observer Variation; D017410:Practice Guidelines as Topic; D015397:Program Evaluation; D011446:Prospective Studies; D015203:Reproducibility of Results