Objective structured assessment of technical competence in transthoracic echocardiography: A validity study in a standardised setting

BMC Medical Education (Impact Factor: 1.22). 03/2013; 13(1):47. DOI: 10.1186/1472-6920-13-47
Source: PubMed


Competence in transthoracic echocardiography (TTE) is unrelated to traditional measures of TTE competence, such as duration of training and number of examinations performed. This study aims to explore aspects of validity of an instrument for structured assessment of echocardiographic technical skills.

The study included 45 physicians with three different clinical levels of echocardiography competence who all scanned the same healthy male following national guidelines. An expert in echocardiography (OG) evaluated all the recorded, de-identified TTE images blindly using the developed instrument for assessment of TTE technical skills. The instrument consisted of both a global rating scale and a procedure specific checklist. Two scores were calculated for each examination: A global rating score and a total checklist score. OG rated ten examinations twice for intra-rater reliability, and another expert rated the same ten examinations for inter-rater reliability. A small pilot study was then performed with focus on content validity. This pilot study included nine physicians who scanned three patients with different pathologies as well as different technical difficulties.

Validity of the TTE technical skills assessment instrument was supported by a significant correlation found between level of expertise and both the global score (Spearman 0.76, p<0.0001) and the checklist score (Spearman 0.74, p<0.001). Both scores were able to distinguish between the three levels of competence that were represented in the physician group. Reliability was supported by acceptable inter- and intra-rater values. The pilot study showed a tendency to improved scores with increasing expertise levels, suggesting that the instrument could also be used when pathologies were present.

We designed and developed a structured assessment instrument of echocardiographic technical skills that showed evidence of validity in terms of high correlations between test scores on a normal person and the level of physician competence, as well as acceptable inter- and intra-rater reliability scores. Further studies should, however, be performed to determine the adequate number of assessments needed to ensure high content validity and reliability in a clinical setting.

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Available from: Dorte Guldbrand Nielsen, Jun 03, 2014
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    ABSTRACT: Background Transthoracic echocardiography (TTE) is a widely used cardiac imaging technique that all cardiologists should be able to perform competently. Traditionally, TTE competence has been assessed by unstructured observation or in test situations separated from daily clinical practice. An instrument for assessment of clinical TTE technical proficiency including a global rating score and a checklist score has previously shown reliability and validity in a standardised setting. As clinical test situations typically have several sources of error giving rise to variance in scores, a more thorough examination of the generalizability of the assessment instrument is needed.Methods Nine physicians performed a TTE scan on the same three patients. Then, two raters rated all 27 TTE scans using the TTE technical assessment instrument in a fully crossed, all random generalizability study. Estimated variance components were calculated for both the global rating and checklist scores. Finally, dependability (phi) coefficients were also calculated for both outcomes in a decision study.ResultsFor global rating scores, 66.6% of score variance can be ascribed to true differences in performance. For checklist scores this was 88.8%. The difference was primarily due to physician-rater interaction. Four random cases rated by one random rater resulted in a phi value of 0.81 for global ratings and two random cases rated by one random rater showed a phi value of 0.92 for checklist scores.Conclusions Using the TTE checklist as opposed to the TTE global rating score had the effect of minimising the largest source of error variance in test scores. Two cases rated by one rater using the TTE checklist are sufficiently reliable for high stakes examinations. As global rating is less time consuming it could be considered performing four global rating assessments in addition to the checklist assessments to account for both reliability and content validity of the assessment.
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