Published Online
on February 16, 2006

A more recent version of this article appeared on March 1, 2006

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Submitted on November 13, 2005
Revised on December 22, 2005
Accepted on January 1, 2006

Interobserver Agreement for the Bedside Clinical Assessment of Suspected Stroke

Peter J. Hand MD, FRACP^*; Janneke A. Haisma MD; Joseph Kwan MD, MRCP; Richard I. Lindley MD, FRACP; Bart Lamont MD; Martin S. Dennis MD, FRCP; and Joanna M. Wardlaw MD, FRCR

From the Division of Clinical Neurosciences, Western General Hospital, Crewe Rd, Edinburgh, UK (J.A.H., J.K., R.I.L., B.L., M.S.D., J.M.W.); and the RMH Stroke Centre (P.J.H.), Department of Neurology, Royal Melbourne Hospital, and Department of Medicine (Neuroscience), Monash University (Alfred Hospital Campus), Victoria, Australia.

^* To whom correspondence should be addressed. E-mail: peter.hand{at}mh.org.au.

Background and Purpose--Stroke remains primarily a clinical diagnosis, with information obtained from history and examination determining further management. We aimed to measure inter-rater reliability for the clinical assessment of stroke, with emphasis on items of history, timing of symptom onset, and diagnosis of stroke or mimic. We explored reasons for poor reliability.

Methods--The study was based in an urban hospital with an acute stroke unit. Pairs of observers independently assessed suspected stroke patients. Findings from history, neurological examination, and the diagnosis of stroke or mimic, were recorded on a standard form. Reliability was measured by the statistic. We assessed the impact of observer experience and confidence, time of assessment, and patient-related factors of age, confusion, and aphasia on inter-rater reliability.

Results--Ninety-eight patients were recruited. Most items of the history and the diagnosis of stroke were found to have moderate to good inter-rater reliability. There was agreement for the hour and minute of symptom onset in only 45% of cases. Observer experience and confidence improved reliability; patient-related factors of confusion and aphasia made the assessment more difficult. There was a trend for worse inter-rater reliability among patients assessed very early and very late after symptom onset.

Conclusions--Clinicians should be aware that inter-rater reliability of the clinical assessment is affected by a variety of factors and is improved by experience and confidence. Our findings have implications for training of doctors who assess patients with suspected stroke and identifies the more reliable components of the clinical assessment.

Key words: classification • diagnosis • observer variation • stroke assessment

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Stroke 2006 37: 769-775. [Abstract] [Full Text] [PDF]

Improving the Clinical Diagnosis of Stroke

Larry B. Goldstein
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