Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
Comparative Study
. 2007 May 15;175(10):1054-60.
doi: 10.1164/rccm.200606-833OC. Epub 2007 Jan 25.

Idiopathic interstitial pneumonia: do community and academic physicians agree on diagnosis?

Affiliations
Comparative Study

Idiopathic interstitial pneumonia: do community and academic physicians agree on diagnosis?

Kevin R Flaherty et al. Am J Respir Crit Care Med. .

Abstract

Rationale: Treatment and prognoses of diffuse parenchymal lung diseases (DPLDs) varies by diagnosis. Obtaining a uniform diagnosis among observers is difficult.

Objectives: Evaluate diagnostic agreement between academic and community-based physicians for patients with DPLDs, and determine if an interactive approach between clinicians, radiologists, and pathologists improved diagnostic agreement in community and academic centers.

Methods: Retrospective review of 39 patients with DPLD. A total of 19 participants reviewed cases at 2 community locations and 1 academic location. Information from the history, physical examination, pulmonary function testing, high-resolution computed tomography, and surgical lung biopsy was collected. Data were presented in the same sequential fashion to three groups of physicians on separate days.

Measurements and main results: Each observer's diagnosis was coded into one of eight categories. A kappa statistic allowing for multiple raters was used to assess agreement in diagnosis. Interactions between clinicians, radiologists, and pathologists improved interobserver agreement at both community and academic sites; however, final agreement was better within academic centers (kappa = 0.55-0.71) than within community centers (kappa = 0.32-0.44). Clinically significant disagreement was present between academic and community-based physicians (kappa = 0.11-0.56). Community physicians were more likely to assign a final diagnosis of idiopathic pulmonary fibrosis compared with academic physicians.

Conclusions: Significant disagreement exists in the diagnosis of DPLD between physicians based in communities compared with those in academic centers. Wherever possible, patients should be referred to centers with expertise in diffuse parenchymal lung disorders to help clarify the diagnosis and provide suggestions regarding treatment options.

PubMed Disclaimer

Figures

<b>Figure 1.</b>
Figure 1.
Schematic representation of the information presented to each of the participants at each step of the study. Individuals made their diagnostic decisions without conferring in steps 1 and 2 and individually after conferring in steps 3–5 (modified from Reference 17). HRCT = high-resolution computed tomography; SLB = surgical lung biopsy.
<b>Figure 2.</b>
Figure 2.
Graphic representation of interobserver agreement (κ) for clinicians, radiologists, and pathologists within academic or community centers at each step of the diagnostic evaluation. Academic clinicians, n = 6; community clinicians, n = 3; academic radiologists, n = 2; community radiologists, n = 2; academic pathologists, n = 4; community pathologists, n = 2.
<b>Figure 3.</b>
Figure 3.
Graphic representation of intraobserver agreement (κ) for clinicians, radiologists, and pathologists within academic or community centers between different steps in the diagnostic process. A high-level κ indicates little change in diagnosis between steps. For community pathologists, the value at step 3/4 represents the change in diagnosis from their individual histopathologic interpretation compared with the diagnosis after discussing the clinical, radiographic, and histopathologic information as a group. For academic pathologists, the value at step 2/3 represents the agreement between the individual pathologist's interpretation and the group pathology discussion; step 3/4 represents the agreement between the group pathology diagnosis before and after discussing the clinical, radiographic, and histopathologic information as a group. For all participants, step 4/5 represents the agreement in diagnosis from the group discussion (step 4) and final consensus (step 5). Academic clinicians, n = 6; community clinicians, n = 3; academic radiologists, n = 2; community radiologists, n = 2; academic pathologists, n = 4; community pathologists, n = 2.
<b>Figure 4.</b>
Figure 4.
Color and character representation of diagnosis for each case (Pt_code) by observer. Columns headed with a “2” represent the diagnosis before pathologic information (for clinicians and radiologists) or clinical/HRCT information (for pathologists). Columns headed with a “5” represent the final diagnosis after a clinical/radiographic/pathologic discussion. Each cell is letter/color coded (I/red = idiopathic pulmonary fibrosis [IPF]; N/light blue = nonspecific interstitial pneumonia [NSIP]; B/dark green = airway/bronchiolar disease; H/yellow = hypersensitivity pneumonia [HP]; R/light green = respiratory bronchiolitis interstitial lung disease [RBILD]; O/orange = other; C/pink = cryptogenic organizing pneumonia [COP]; S/dark blue = systemic collagen vascular disease–associated interstitial lung disease). For example, community clinician 1 (CC1) initially diagnosed case 365 as NSIP, but changed to a diagnosis of IPF after a clinical/radiographic/pathologic discussion. IIP = idiopathic interstitial pneumonia.

Comment in

References

    1. Flaherty KR, Toews GB, Travis WD, Colby TV, Kazerooni EA, Gross BH, Jain A, Strawderman RL III, Paine R III, Flint A, et al. Clinical significance of histological classification of idiopathic interstitial pneumonia. Eur Respir J 2002;19:275–283. - PubMed
    1. Flaherty KR, Travis WD, Colby TV, Toews GB, Kazerooni EA, Gross BH, Jain A, Strawderman RL III, Flint A, Lynch JP III, et al. Histologic variability in usual and nonspecific interstitial pneumonias. Am J Respir Crit Care Med 2001;164:1722–1727. - PubMed
    1. Katzenstein ALA, Fiorelli RF. Nonspecific interstitial pneumonia/fibrosis: histologic features and clinical significance. Am J Surg Pathol 1994;18:136–147. - PubMed
    1. Nagai S, Kitaichi M, Itoh H, Nishimura K, Izumi T, Colby TV. Idiopathic nonspecific interstitial pneumonia/fibrosis: comparison with idiopathic pulmonary fibrosis and BOOP. Eur Respir J 1998;12:1010–1019. - PubMed
    1. Nicholson AG, Colby TV, DuBois RM, Hansell DM, Wells AU. The prognostic significance of the histologic pattern of interstitial pneumonia in patients presenting with the clinical entity of cryptogenic fibrosing alveolitis. Am J Respir Crit Care Med 2000;162:2213–2217. - PubMed

Publication types