title: A pilot study of clinical agreement in cardiovascular preparticipation examinations: how good is the standard of care?
abstract: OBJECTIVE
  To evaluate the interobserver agreement between physicians regarding a abnormal cardiovascular assessment on athletic preparticipation examinations.
  
  
  METHODS
  Cross-sectional clinical survey.
  
  
  METHODS
  Outpatient Clinic, United States Military Academy, West Point, NY.
  
  
  METHODS
  We randomly selected 101 out of 539 cadet-athletes presenting for a preparticipation examination. Two primary care sports medicine fellows and a cardiologist examined the cadets.
  
  
  METHODS
  After obtaining informed consent from all participants, all 3 physicians separately evaluated all 101 cadets. The physicians recorded their clinical findings and whether they thought further cardiovascular evaluation (echocardiography) was indicated.
  
  
  METHODS
  Rate of referral for further cardiovascular evaluation, clinical agreement between sports medicine fellows, and clinical agreement between sports medicine fellows and the cardiologist.
  
  
  RESULTS
  Each fellow referred 6 of the 101 evaluated cadets (5.9%). The cardiologist referred none. Although each fellow referred 6 cadets, only 1 cadet was referred by both. The kappa statistic for clinical agreement between fellows is 0.114 (95% CI, -0.182 to 0.411). There was no clinical agreement between the fellows and the cardiologist.
  
  
  CONCLUSIONS
  This pilot study reveals a low level of agreement between physicians regarding which athletes with an abnormal examination deserved further testing. It challenges the standard of care and questions whether there is a need for improved technologies or improved training in cardiovascular clinical assessment.
authors.affiliation: Primary Care Sports Medicine, Uniformed Services University, Bethesda, MD 20814, USA. foconnor@USUHS.mil
authors.forename: Francis G
authors.initials: FG
authors.lastname: O'Connor
authors.forename: Jeremy D
authors.initials: JD
authors.lastname: Johnson
authors.forename: Mark
authors.initials: M
authors.lastname: Chapin
authors.forename: Ralph G
authors.initials: RG
authors.lastname: Oriscello
authors.forename: Dean C
authors.initials: DC
authors.lastname: Taylor
mesh_terms: D000293:Adolescent; D000328:Adult; D001265:Athletic Injuries / Q000517:prevention & control; D002318:Cardiovascular Diseases / Q000175:diagnosis* / Q000453:epidemiology; D003430:Cross-Sectional Studies; D015150:Echocardiography, Doppler / Q000592:standards / Q000639:trends; D005260:Female; D006287:Health Planning Guidelines; D006301:Health Services Needs and Demand; D006337:Heart Murmurs / Q000175:diagnosis* / Q000453:epidemiology; D006801:Humans; D015994:Incidence; D008297:Male; D008403:Mass Screening / Q000592:standards* / Q000639:trends; D015588:Observer Variation; D010808:Physical Examination / Q000592:standards / Q000639:trends; D010865:Pilot Projects; D018570:Risk Assessment; D012572:School Health Services / Q000592:standards* / Q000639:trends; D013177:Sports; D017749:Total Quality Management