Impact of acquisition and interpretation on total inter-observer variability in echocardiography: results from the quality assurance program of the STAAB cohort study
Variability related to image acquisition and interpretation is an important issue of echocardiography in clinical trials. Nevertheless, there is no broadly accepted standard method for quality assessment of echocardiography in clinical research reports. We present analyses based on the echocardiography quality-assurance program of the ongoing STAAB cohort study (characteristics and course of heart failure stages A–B and determinants of progression). In 43 healthy individuals (mean age 50 ± 14 years; 18 females), duplicate echocardiography scans were acquired and mutually interpreted by one of three trained sonographers and an EACVI certified physician, respectively. Acquisition (AcV), interpretation (InV), and inter-observer variability (IOV; i.e., variability between the acquisition-interpretation sequences of two different observers), were determined for selected M-mode, B-mode, and Doppler parameters. We calculated Bland–Altman upper 95% limits of absolute differences, implying that 95% of measurement differences were smaller/equal to the given value: e.g. LV end-diastolic volume (mL): 25.0, 25.0, 27.9; septal e′ velocity (cm/s): 3.03, 1.25, 3.58. Further, 90, 85, and 80% upper limits of absolute differences were determined for the respective parameters. Both, acquisition and interpretation, independently and sizably contributed to IOV. As such, separate assessment of AcV and InV is likely to aid in echocardiography training and quality-assurance. Our results further suggest to routinely determine IOV in clinical trials as a comprehensive measure of imaging quality. The derived 95, 90, 85, and 80% upper limits of absolute differences are suggested as reproducibility targets of future studies, thus contributing to the international efforts of standardization in quality-assurance.
KeywordsEchocardiography Quality Reproducibility Variability Observer Acquisition
Peak late- diastolic lengthening velocity
Peak early diastolic lengthening velocity
European Association of Cardiovascular Imaging
Intraclass correlation coefficient
Characteristics and course of heart failure stages A–B and determinants of progression cohort study
Limits of agreement
Left ventricular end-diastolic diameter
Left ventricular end-diastolic volume
Left ventricular end-systolic volume
Mitral annular plane systolic excursion
Peak systolic shortening velocity
Tricuspid annular plane systolic excursion
Tissue Doppler imaging
We thank Martina Bauer, lead sonographer of the Comprehensive Heart Failure Center (CHFC), for excellent echocardiography teaching, as well as Jasmin Simon, Martin Cramer and Frances Knobeloch, CHFC sonographers, for their valuable contribution to this study.
The study is supported by the German Ministry of Research and Education within the Comprehensive Heart Failure Centre Würzburg (BMBF 01EO1004 and 01EO1504). This publication was funded by the German Research Foundation (DFG) and the University of Wuerzburg in the funding programme Open Access Publishing.
Compliance with ethical standards
Conflict of interest
CM reports a co-investigatorship in a trial sponsored by NOVARTIS, a travel grant from THERMO FISHER and a speaker honorarium from AMGEN. GG reports grants from University Göttingen within the FIND-AF-randomized trial (FIND-AF-randomized is supported by an unrestricted grant to the University Göttingen from Boehringer-Ingelheim), grants from University Göttingen within DZHK analysis projects (the DZHK is funded by a BMBF grant), personal fees from Charité - Universitätsmedizin Berlin within the TIM-HF-II trial for data safety and monitoring board membership (TIM-HF-II is supported by a BMBF grant to the Charité), grants from University Hospital Würzburg within the MOOD-HF trial for biometry and steering committee membership (MOOD-HF is supported by a BMBF grant and an unrestricted grant to the University Hospital Würzburg from Lundbeck), outside the submitted work. PUH reports research grants from the German Ministry of Research and Education, European Union, Charité, Berlin Chamber of Physicians, German Parkinson Society, University Hospital Würzburg, Robert-Koch-Institute, German Heart Foundation, Charité–Universitätsmedizin Berlin (within MonDAFIS; MonDAFIS is supported by an unrestricted research grant to the Charité from Bayer), University Göttingen (within FIND-AF-randomized; FIND-AF randomized is supported by an unrestricted research grant to the University Göttingen from Boehringer-Ingelheim), and University Hospital Heidelberg (within RASUNOA-prime; RASUNOA-prime is supported by an unrestricted research grant to the University Hospital Heidelberg from Bayer, BMS, Boehringer-Ingelheim, Daiichi Sankyo), outside submitted work. SS reports research grants from the German Ministry of Education and Research, European Union, University Hospital Würzburg; participation in Data Safety Monitoring and Event Adjudication Boards in trials sponsored by ROCHE and MEDTRONIC; principal investigator in trials (co-)sponsored by BOEHRINGER, NOVARTIS, BAYER, LUNDBECK; speaker honaria by BOEHRINGER, SERVIER, NOVARTIS, ASTRA-ZENECA, PFIZER, BAYER. MW declares that he has no conflict of interest. TT declares that she has no conflict of interest. MB declares that she has no conflict of interest.
The STAAB cohort study protocol and procedures received positive votes from the Ethics Committee of the Medical Faculty (vote 98/13) as well as from the data protection officer of the University of Würzburg (J-117.605-09/13). All procedures performed in this study were in accordance with the ethical standards of the institutional and national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
All participants provided written informed consent prior to any study examination.
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