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Diagnostic & investigative approach of consultant neurologists in a real-world clinical setting
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  • Chris Aitchison,
  • Daniel Blackburn,
  • Aijaz Khan,
  • Richard Grünewald,
  • Tom Jenkins
Chris Aitchison
The University of Sheffield
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Daniel Blackburn
The University of Sheffield Institute for Translational Neuroscience
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Aijaz Khan
Sheffield Teaching Hospitals NHS Foundation Trust
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Richard Grünewald
Sheffield Teaching Hospitals NHS Foundation Trust
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Tom Jenkins
The University of Sheffield Institute for Translational Neuroscience
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Abstract

Background: Whilst core curricula in neurology are nationally standardised, in real-world clinical practice, different approaches may be taken by individual consultants. In this study, we investigated: (1) variance in diagnostic and investigative practice, using a case-based analysis of inter-rater agreement; (2) potential importance of any differences in terms of patient care; (3) relationships between clinical experience, diagnostic certainty, diagnostic peer-agreement and investigative approach; (4) development of novel individualised metrics to facilitate appraisal. Methods: Four neurologists with 0-23 years’ experience at consultant level provided diagnosis, certainty (10-point Likert scale), and investigative approach for 200 consecutive general neurology outpatients seen by a newly qualified consultant. Diagnostic agreement was evaluated by percentage agreement. The potential importance of any diagnostic differences was assigned a score by the evaluating neurologist (6-point Likert scale). Associations between diagnostic agreement, certainty and investigative approach were assessed using Spearman correlation, logistic and ordinal regression, and reported as individualiszd metrics for each rater. Results: Diagnostic peer-agreement was 4/4, 3/4, 2/4 and 1/4 in 50%, 28%, 20% and 3% of cases, respectively. In 17%, differences in patient management were judged potentially important. Investigation rates were 42-73%. Mean diagnostic certainty ranged between 6.2/10 (SD 2.1) to 7.7/10 (SD 2.2) between least and most experienced consultants. Greater diagnostic certainty was associated with greater diagnostic peer-agreement (individual-rater regression coefficients 0.30-0.51, p<0.01) and lower odds of arranging investigations (individual-rater odds ratios 0.58-0.78, p<0.01). Conclusions: Variance in diagnostic and investigative practice between consultant neurologists exits and may result in differing management. Mean diagnostic certainty increased numerically with experience and was statistically associated with greater diagnostic peer-agreement and lower investigation rates. Metrics reflecting concordance with peers, and relationships to diagnostic confidence, could inform reflective practice.

Peer review status:ACCEPTED

07 Jul 2020Submitted to International Journal of Clinical Practice
08 Jul 2020Submission Checks Completed
08 Jul 2020Assigned to Editor
11 Jul 2020Reviewer(s) Assigned
23 Aug 2020Review(s) Completed, Editorial Evaluation Pending
18 Sep 20201st Revision Received
19 Sep 2020Submission Checks Completed
19 Sep 2020Assigned to Editor
19 Sep 2020Reviewer(s) Assigned
05 Oct 2020Review(s) Completed, Editorial Evaluation Pending
18 Oct 20202nd Revision Received
19 Oct 2020Submission Checks Completed
19 Oct 2020Assigned to Editor
19 Oct 2020Reviewer(s) Assigned
02 Nov 2020Review(s) Completed, Editorial Evaluation Pending
03 Nov 20203rd Revision Received
03 Nov 2020Submission Checks Completed
03 Nov 2020Reviewer(s) Assigned
03 Nov 2020Assigned to Editor
03 Nov 2020Review(s) Completed, Editorial Evaluation Pending
05 Nov 2020Editorial Decision: Accept