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CLINICAL DISAGREEMENT CLINICAL DISAGREEMENT
Iwan Iwan Dwiprahasto Dwiprahasto
Department of Pharmacology/CE&BU/MMR Department of Pharmacology/CE&BU/MMR
Faculty of Medicine, Faculty of Medicine, UGM UGM
TIA 195 (38%)
Not TIA 317 (62%)
Migraine 52 (10%)
Syncope 48 (9%)
Possible TIA* 46 (9%)
Funny turn 45 (9%)
Isolated vertigo 33 (6%)
Epilepsy 29 (6%)
Transient global amnesia 17 (3%)
Lone bilateral blindness 14 (3%)
Isolated diplopia 4 (0.8%)
Drop attack# 3 (0.6%)
Intracranial meningioma 2 (0.4%)
Miscellaneous 24 (5%)
Diagnosis of suspected TIA by general practitioners in the Diagnosis of suspected TIA by general practitioners in the Diagnosis of suspected TIA by general practitioners in the Diagnosis of suspected TIA by general practitioners in the
community (n=512) community (n=512) community (n=512) community (n=512)
Diagnosis of stroke and transient ischemic attack
Diagnosis of stroke and transient ischemic attack
Background Background Background Background
Repeat
mesurement
CLINICAL CLINICAL
DISAGREEMENT DISAGREEMENT
INTRA OBSERVER INTRA OBSERVER
VARIATION VARIATION
INTER OBSERVER INTER OBSERVER
VARIATION VARIATION
OBSERVER OBSERVER
VARIATION VARIATION
When does clinical disagreement occur? When does clinical disagreement occur?
During anamnesis
Physical examination
Interpreting Laboratory findings
Interpreting Radioloic finding
Deciding treatment
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Why clinical disagreement happen? Why clinical disagreement happen?
Doctor Doctor
Patient Patient
Procedure Procedure
Tired, anger, stress
Biologic
variation
Cough & cold: bacterial
infection
Experience-
based
Fever: DHF or malaria
Misclassific
ation
Working in endemic
area of malaria
Bias
Different reference
Mis-
diagnosis
Doctor Doctor
Why clinical disagreement happen? Why clinical disagreement happen?
Tired
Fasting etc
Biologic
variations
Hypoglicaemia
Hyperuricemia
Disease
effect
Food recall
Drug taking
within previous
month
Recall
bias
Drowsines
Hang over
Drug
effect
Patients factor
Noisy, warm,
humid
Environment
Poor
communication,
tired, bad mood
Doctor-
patient
relationship
Not standard
Not calibrated
obsolete
Instrument
Measurment Measurment
Why clinical disagreement happen? Why clinical disagreement happen?
Oftalmologist 2
R-mild R-severe
R-mild 46 10 56
R-severe 12 32 44
58 42 100
Oftalmo-
logis-1
Observed agreement = ? Observed agreement = ? Observed agreement = ? Observed agreement = ?
46 + 32 46 + 32 46 + 32 46 + 32
100 100 100 100
= = = = 78 78 78 78 % %% %
Detecting Detecting Retinopathy by Retinopathy by 2 2 Opthalmologist Opthalmologist
pe = [(n1/n) * (m1/n)] + [(no/n) * (mo/n)]
(po (pope) pe)
(1 (1pe) pe)
Kappa = Kappa =
p0 =
a+d
n
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58 58 58 58 42 42 42 42
56 56 56 56
44 44 44 44
100 100 100 100
Chance agreement = ? Chance agreement = ? Chance agreement = ? Chance agreement = ?
32 32 32 32, ,, ,5 5 5 5 + + + + 18 18 18 18, ,, ,5 55 5
100 100 100 100
= 51 % = 51 % = 51 % = 51 %
Oftalmo Oftalmo Oftalmo Oftalmo- -- -
logis logis logis logis- -- -1 11 1
Oftalmologis Oftalmologis Oftalmologis Oftalmologis- -- -2 22 2
R RR R- -- -ringan ringan ringan ringan R RR R- -- -berat berat berat berat
R RR R- -- -ringan ringan ringan ringan
R RR R- -- -berat berat berat berat
58/100 x 56 58/100 x 56 58/100 x 56 58/100 x 56
= = = = 32,5 32,5 32,5 32,5
58 58 58 58/ // /100 100 100 100 x x x x 44 44 44 44
= = = = 25 25 25 25, ,, ,5 55 5
42/100 x 56 42/100 x 56 42/100 x 56 42/100 x 56
= = = = 23,5 23,5 23,5 23,5
42/100 x 44 42/100 x 44 42/100 x 44 42/100 x 44
= = = = 18,5 18,5 18,5 18,5







Observed agreement Observed agreement
46 + 32/100 = 78% 46 + 32/100 = 78%
Agreement expected on Agreement expected on
the basis of chance the basis of chance
32,5 + 18,5/100 = 51% 32,5 + 18,5/100 = 51%
Agreement Agreement
beyond beyond
chance chance
78 78- -51= 27% 51= 27%
100 100% %
100% 100%
100% 100%
0% 0%
0% 0%
Potential agreement Potential agreement
beyond chance beyond chance
100 100 - - 51 = 49% 51 = 49%
No agreement No agreement Complete agreement Complete agreement
KAPPA = KAPPA = -------------------------------- -------------------------------- = = ----- ----- = = 00,,55 55
Actual agreement beyond chance Actual agreement beyond chance
Potential agreement beyond chance Potential agreement beyond chance
27 27
49 49
<0 Poor
0 - 0.20 Slight
0.21 - 0.40 Fair
0.41 - 0.60 Moderate
0.61 - 0.80 Substantial
0.81 - 1.0 Almost perfect
Value of kappa Strength of agreement