Accuracy of Physicians' Electrocardiogram Interpretations: A Systematic Review and Meta-analysis

Abstract

Importance: The electrocardiogram (ECG) is the most common cardiovascular diagnostic test. Physicians' skill in ECG interpretation is incompletely understood.

Objectives: To identify and summarize published research on the accuracy of physicians' ECG interpretations.

Data sources: A search of PubMed/MEDLINE, Embase, Cochrane CENTRAL (Central Register of Controlled Trials), PsycINFO, CINAHL (Cumulative Index to Nursing and Allied Health), ERIC (Education Resources Information Center), and Web of Science was conducted for articles published from database inception to February 21, 2020.

Study selection: Of 1138 articles initially identified, 78 studies that assessed the accuracy of physicians' or medical students' ECG interpretations in a test setting were selected.

Data extraction and synthesis: Data on study purpose, participants, assessment features, and outcomes were abstracted, and methodological quality was appraised with the Medical Education Research Study Quality Instrument. Results were pooled using random-effects meta-analysis.

Main outcomes and measures: Accuracy of ECG interpretation.

Results: Of 1138 studies initially identified, 78 assessed the accuracy of ECG interpretation. Across all training levels, the median accuracy was 54% (interquartile range [IQR], 40%-66%; n = 62 studies) on pretraining assessments and 67% (IQR, 55%-77%; n = 47 studies) on posttraining assessments. Accuracy varied widely across studies. The pooled accuracy for pretraining assessments was 42.0% (95% CI, 34.3%-49.6%; n = 24 studies; I2 = 99%) for medical students, 55.8% (95% CI, 48.1%-63.6%; n = 37 studies; I2 = 96%) for residents, 68.5% (95% CI, 57.6%-79.5%; n = 10 studies; I2 = 86%) for practicing physicians, and 74.9% (95% CI, 63.2%-86.7%; n = 8 studies; I2 = 22%) for cardiologists.

Conclusions and relevance: Physicians at all training levels had deficiencies in ECG interpretation, even after educational interventions. Improved education across the practice continuum appears warranted. Wide variation in outcomes could reflect real differences in training or skill or differences in assessment design.

Figure 1.. Trial Flow Diagram

Figure 2.. Physician Electrocardiogram (ECG) Interpretation Accuracy Without Additional ECG Training, for All Training Levels Combined

Basic 1 indicates a single straightforward diagnosis; basic 2, 2 or more straightforward diagnoses; Card, cardiologists in practice or cardiology fellows; I, ischemia/infarction, M, metabolism/inflammation (eg, pericarditis, hyperkalemia, or drug effect); MS, medical students; N, normal; O, other; PG, postgraduate physicians (residents); R, rhythm; S, structure (eg, hypertrophy or conduction block). Boxes indicate the mean accuracy score for each study. The diamond and dashed vertical line indicate the median score across studies.

Figure 3.. Random-Effects Meta-analysis of Physician Electrocardiogram (ECG) Interpretation Accuracy Without Additional ECG Training, for Medical Students and Resident Physicians

See Figure 2 for explanation of abbreviations and difficulty levels. Boxes indicate the mean accuracy score for each study, diamonds indicate pooled estimates across studies, and horizontal lines indicate 95% CIs.

Figure 4.. Random-Effects Meta-analysis of Physician Electrocardiogram (ECG) Interpretation Accuracy Without Additional ECG Training, for Practicing Physicians and Cardiologists and Cardiology Fellows

See Figure 2 for explanation of abbreviations and difficulty levels. Boxes indicate the mean accuracy score for each study, diamonds indicate pooled estimates across studies, and horizontal lines indicate 95% CIs.