title: Improved interobserver variability and accuracy of echocardiographic visual left ventricular ejection fraction assessment through a self-directed learning program using cardiac magnetic resonance images.
abstract: BACKGROUND
  Although not recommended in isolation, visual estimation of echocardiographic ejection fraction (EF) is widely applied to confirm quantitative EF. However, interobserver variability for EF estimation has been reported to be as high as 14%. The aim of this study was to determine whether self-directed education could improve the accuracy and interobserver variability of visual estimation of EF and whether a multireader estimate improves measurement precision.
  
  
  METHODS
  Thirty-one participants provided single-point EF estimates for 30 echocardiograms with a spectrum of EFs, image quality, and clinical contexts in patients undergoing cardiac magnetic resonance (CMR) within 48 hours. Participants received their own case-by-case variance from CMR EF, and the 10 cases with the largest reader variability were discussed along with corresponding CMR images. Self-directed learning was undertaken by side-by-side review of echocardiographic and CMR images. Two months later, 20 new cases were shown to the same 31 participants, using the same methodology.
  
  
  RESULTS
  The baseline interobserver variability of ±0.120 improved to ±0.097 after the intervention. EF misclassification (defined as ±0.05 of CMR EF) was reduced from 56% to 47% (P < .001), and the intervention also resulted in a decrease in the absolute difference between CMR and echocardiography for all cases and all readers (from 0.07 ± 0.01 to 0.06 ± 0.01, P = .0001). This improvement was most prominent for the readers with lower baseline accuracy. A combined physician-sonographer EF estimate improved the precision of EF determination by 25% compared with individual reads.
  
  
  CONCLUSIONS
  In readers with varying levels of experience, a simple, mostly self-directed intervention modestly decreased interobserver variability and improved the accuracy of EF measurements. Combined physician-sonographer EF reporting improved the precision of EF estimates.
authors.affiliation: Department of Cardiology, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Paaladinesh
authors.initials: P
authors.lastname: Thavendiranathan
authors.forename: Zoran B
authors.initials: ZB
authors.lastname: Popović
authors.forename: Scott D
authors.initials: SD
authors.lastname: Flamm
authors.forename: Arun
authors.initials: A
authors.lastname: Dahiya
authors.forename: Richard A
authors.initials: RA
authors.lastname: Grimm
authors.forename: Thomas H
authors.initials: TH
authors.lastname: Marwick
mesh_terms: D000328:Adult; D003479:Curriculum; D004452:Echocardiography / Q000706:statistics & numerical data*; D005260:Female; D006801:Humans; D019028:Magnetic Resonance Imaging, Cine / Q000706:statistics & numerical data*; D008297:Male; D008875:Middle Aged; D015588:Observer Variation; D009820:Ohio; D018794:Problem-Based Learning / Q000379:methods* / Q000706:statistics & numerical data*; D011361:Professional Competence / Q000706:statistics & numerical data*; D015203:Reproducibility of Results; D020377:Self Efficacy; D012680:Sensitivity and Specificity; D013318:Stroke Volume; D018487:Ventricular Dysfunction, Left / Q000175:diagnosis*; D055815:Young Adult
keywords: CMR; Cardiac MRI; Cardiac magnetic resonance; EF; Ejection fraction; IOV; Interobserver variability; LV; LVEF; Left ventricular; Left ventricular ejection fraction; MSE; Mean squared error; Quality assessment and improvement; Self-directed education; Visual ejection fraction