title: Human factors as a source of error in peak Doppler velocity measurement.
abstract: OBJECTIVE
  The study was conducted to assess the error and variability that results from human factors in Doppler peak velocity measurement. The positioning of the Doppler sample volume in the vessel, adjustment of the Doppler gain and angle, and choice of waveform display size were investigated. We hypothesized that even experienced vascular technologists in a laboratory accredited by the Intersocietal Commission for Accreditation of Vascular Laboratories make significant errors and have significant variability in the subjective adjustments made during measurements.
  
  
  METHODS
  Problems of patient variability were avoided by having the four technologists measure peak velocities from an in vitro pulsatile flow model with unstenosed and 61% stenosed tubes. To evaluate inaccurate angle and sample volume positioning, a probe holder was used in some of the experiments to fix the Doppler angle at 60 degrees. The effect of Doppler gain was studied at three settings--low, ideal, and saturated gains--that were standardized from the ideal level chosen by consensus amongst the technologists. Two waveform display sizes were also investigated. Peak velocity measurement was assessed by comparison with true peak velocities. For each variable studied, average peak velocities were calculated from the 10 measurements made by each technologist and used to find the percent error from the true value, and the coefficient of variation was used to measure the variability.
  
  
  RESULTS
  Doppler angle, sample volume placement, and the Doppler gain were the most significant sources of error and variability. Inaccurate angle and placement increased the variability in measurements from 1% to 2% (range) to 4% to 6% for the straight tube and from 1% to 2% to 3% to 9% for the 61% stenosis. The peak velocity error was increased from 9% to 13% to 7% to 28% for the stenosis. Both measurement error and variability were strongly dependent on the Doppler gain level. At low gain, the error was approximately 10% less than the true value and at saturated gain, 20% greater. The display size only affected measurements from the stenosed tube, increasing the error from 9% to 13% to 15% to 24%.
  
  
  CONCLUSIONS
  Major factors affecting Doppler peak velocity measurement error and variability were identified. Inaccurate angle and sample volume placement increased the variability. The presence of a stenosis was found to increase the measurement errors. The error was found to depend on the Doppler gain setting, with greater variability at low and saturated gains and on the display size with a stenosis.
  
  
  CONCLUSIONS
  Doppler ultrasound peak velocity measurements are widely used for the diagnostic assessment of the severity of arterial stenoses. However, it is known that these measurements are often in error. We have identified subjective human factors introduced by the technologist and assessed their contribution to peak velocity measurement error and variability. It is to be hoped that by understanding this, improvements in the machine design and measurement methods can be made that will result in improved measurement accuracy and reproducibility.
authors.affiliation: Institute of Biomaterials and Biomedical Engineering, University of Toronto, Ontario, Canada. elaine.lui@utoronto.ca
authors.forename: Elaine Y L
authors.initials: EY
authors.lastname: Lui
authors.forename: Aaron H
authors.initials: AH
authors.lastname: Steinman
authors.forename: Richard S C
authors.initials: RS
authors.lastname: Cobbold
authors.forename: K Wayne
authors.initials: KW
authors.lastname: Johnston
mesh_terms: D016477:Artifacts; D001783:Blood Flow Velocity; D001808:Blood Vessels / Q000000981:diagnostic imaging*; D006801:Humans; D008955:Models, Cardiovascular; D015588:Observer Variation; D018608:Ultrasonography, Doppler / Q000706:statistics & numerical data*