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Published ahead of print on January 25, 2007, doi:10.1164/rccm.200606-833OC
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American Journal of Respiratory and Critical Care Medicine Vol 175. pp. 1054-1060, (2007)
© 2007 American Thoracic Society
doi: 10.1164/rccm.200606-833OC

Original Article

Idiopathic Interstitial Pneumonia

Do Community and Academic Physicians Agree on Diagnosis?

Kevin R. Flaherty1, Adin-Cristian Andrei2, Talmadge E. King, Jr.3, Ganesh Raghu4, Thomas V. Colby5, Athol Wells6, Nadir Bassily7, Kevin Brown8, Roland du Bois6, Andrew Flint9, Steven E. Gay1, Barry H. Gross10, Ella A. Kazerooni10, Robert Knapp11, Edmund Louvar7, David Lynch8, Andrew G. Nicholson6, John Quick12, Victor J. Thannickal1, William D. Travis12, James Vyskocil7, Frazer A. Wadenstorer7, Jeffrey Wilt11, Galen B. Toews1, Susan Murray2 and Fernando J. Martinez1

1 Division of Pulmonary and Critical Care Medicine, University of Michigan Health System, Ann Arbor, Michigan; 2 Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, Michigan; 3 University of California, San Francisco, San Francisco, California; 4 University of Washington, Seattle, Washington; 5 Mayo Clinic, Scottsdale, Arizona; 6 Royal Brompton Hospital, London, United Kingdom; 7 McLaren Regional Medical Center, Flint, Michigan; 8 National Jewish Medical Center, Denver, Colorado; Departments of 9 Pathology and 10 Radiology, University of Michigan Health System, Ann Arbor, Michigan; 11 Spectrum Health System, Grand Rapids, Michigan; and 12 Memorial Sloan Kettering, New York, New York

Correspondence and requests for reprints should be addressed to Kevin R. Flaherty, M.D., M.S., 3916 Taubman Center, 1500 East Medical Center Drive, Ann Arbor, MI 48109-0360. E-mail: flaherty{at}umich.edu

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.

Key Words: academic • community • diagnosis • nonspecific interstitial pneumonia • usual interstitial pneumonia


AT A GLANCE COMMENTARY

Scientific Knowledge on the Subject
The treatment and prognosis of idiopathic interstitial pneumonias varies by diagnosis. An interactive clinical–radiographic–pathologic approach to diagnosis improves final diagnostic agreement.

What This Study Adds to the Field
Significant disagreement exists in the diagnosis of idiopathic interstitial pneumonia between physicians based in community and those in academic centers. Patients with suspected diffuse parenchymal lung disorders should be referred to centers with expertise in this area to help clarify the diagnosis and for suggestions regarding treatment.

 

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