Inter-radiologist agreement for CT scoring of pediatric splenic injuries and effect on an established clinical practice guideline.
BACKGROUND
The American Pediatric Surgical Association (APSA) advocates for the use of a clinical practice guideline to direct management of hemodynamically stable pediatric spleen injuries. The clinical practice guideline is based on the CT score of the spleen injury according to the American Association for the Surgery of Trauma (AAST) CT scoring system.


OBJECTIVE
To determine the potential effect of radiologist agreement for CT scoring of pediatric spleen injuries on an established APSA clinical practice guideline.


METHODS
We retrospectively analyzed blunt splenic injuries occurring in children from January 2007 to January 2012 at a single level 1 trauma center (n = 90). Abdominal CT exams performed at clinical presentation were reviewed by four radiologists who documented the following: (1) splenic injury grade (AAST system), (2) arterial extravasation and (3) pseudoaneurysm. Inter-rater agreement for AAST injury grade was assessed using the multi-rater Fleiss kappa and Kendall coefficient of concordance. Inter-rater agreement was assessed using weighted (AAST injury grade) or prevalence-adjusted bias-adjusted (binary measures) kappa statistics; 95% confidence intervals were calculated. We evaluated the hypothetical effect of radiologist disagreement on an established APSA clinical practice guideline.


RESULTS
Inter-rater agreement was good for absolute AAST injury grade (kappa: 0.64 [0.59–0.69]) and excellent for relative AAST injury grade (Kendall w: 0.90). All radiologists agreed on the AAST grade in 52% of cases. Based on an established clinical practice guideline, radiologist disagreement could have changed the decision for intensive care management in 11% (10/90) of children, changed the length of hospital stay in 44% (40/90), and changed the time to return to normal activity in 44% (40/90).


CONCLUSIONS
Radiologist agreement when assigning splenic AAST injury grades is less than perfect, and disagreements have the potential to change management in a substantial number of pediatric patients.
Jessica R
JR
Leschied
Michael B
MB
Mazza
Matthew
M
Davenport
Suzanne T
ST
Chong
Ethan A
EA
Smith
Carrie N
CN
Hoff
Maria F
MF
Ladino-Torres
Shokoufeh
S
Khalatbari
Peter F
PF
Ehrlich
Jonathan R
JR
Dillman
D000293:Adolescent; D002648:Child; D002675:Child, Preschool; D005260:Female; D019983:Guideline Adherence; D006801:Humans; D007223:Infant; D008297:Male; D015588:Observer Variation; D017410:Practice Guidelines as Topic; D010818:Practice Patterns, Physicians'; D011860:Radiography, Abdominal; D011871:Radiology / Q000592:standards; D015203:Reproducibility of Results; D012680:Sensitivity and Specificity; D013154:Spleen / Q000000981:diagnostic imaging* / Q000293:injuries*; D014057:Tomography, X-Ray Computed / Q000592:standards*; D015599:Trauma Severity Indices; D014481:United States; D014949:Wounds, Nonpenetrating / Q000000981:diagnostic imaging*