Clinical Investigation
Left Ventricular Mechanics and Function
Improved Interobserver Variability and Accuracy of Echocardiographic Visual Left Ventricular Ejection Fraction Assessment through a Self-Directed Learning Program Using Cardiac Magnetic Resonance Images

https://doi.org/10.1016/j.echo.2013.07.017Get rights and content

Background

Although not recommended in isolation, visual estimation of echocardiographic ejection fraction (EF) is widely applied to confirm quantitative EF. However, interobserver variability for EF estimation has been reported to be as high as 14%. The aim of this study was to determine whether self-directed education could improve the accuracy and interobserver variability of visual estimation of EF and whether a multireader estimate improves measurement precision.

Methods

Thirty-one participants provided single-point EF estimates for 30 echocardiograms with a spectrum of EFs, image quality, and clinical contexts in patients undergoing cardiac magnetic resonance (CMR) within 48 hours. Participants received their own case-by-case variance from CMR EF, and the 10 cases with the largest reader variability were discussed along with corresponding CMR images. Self-directed learning was undertaken by side-by-side review of echocardiographic and CMR images. Two months later, 20 new cases were shown to the same 31 participants, using the same methodology.

Results

The baseline interobserver variability of ±0.120 improved to ±0.097 after the intervention. EF misclassification (defined as ±0.05 of CMR EF) was reduced from 56% to 47% (P < .001), and the intervention also resulted in a decrease in the absolute difference between CMR and echocardiography for all cases and all readers (from 0.07 ± 0.01 to 0.06 ± 0.01, P = .0001). This improvement was most prominent for the readers with lower baseline accuracy. A combined physician-sonographer EF estimate improved the precision of EF determination by 25% compared with individual reads.

Conclusions

In readers with varying levels of experience, a simple, mostly self-directed intervention modestly decreased interobserver variability and improved the accuracy of EF measurements. Combined physician-sonographer EF reporting improved the precision of EF estimates.

Section snippets

Baseline Assessment

Thirty two-dimensional transthoracic echocardiograms with (n = 8) and without (n = 22) contrast administration for left ventricular (LV) opacification were chosen on the basis of the availability of a CMR study with appropriate images for LVEF measurement within 48 hours of echocardiography and without any intervening procedures or changes in clinical status. Selected clips (consisting of three apical views as well as basal, mid, and apical short-axis views as available, displayed with equal

Cases and Participants

Among the 31 participants 11 were sonographers and 20 were physicians. The median duration of experience among the sonographers was 3.5 years (interquartile range, 24.3 years; range, 1–32 years), while among the physicians, it was 9.5 years (interquartile range, 19.5 years; range, 1–36 years). All sonographers were full-time clinical staff members who perform on average 8–10 echocardiographic studies per day and provide complete preliminary reports, including LVEF estimation. The physicians

Discussion

Continuous quality improvement is an essential component of an echocardiography laboratory. However, quality control programs can be organizationally challenging.8 This study illustrates the use of a self-directed program to improve the IOV and accuracy of visual EF estimation among a group of sonographers and cardiologists, with the suggestion that those with lower baseline accuracy are the greatest beneficiaries. In addition, we found that the use of combined physician-sonographer EF

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