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Inter-rater agreement on post-hoc interpretation of uroflowmetry-electromyography in children with non-neurogenic lower urinary tract dysfunction.
Israel P. Nosnik, MD, Mark A. Faasse, MD MPH, Dawn Diaz-Saldano, RN, MSN, CPNP, Dennis B. Liu, MD, Jennifer Schreiber, RN, MSN, CPNP, Kavita S. Hodgkins, MD, Elizabeth B. Yerkes, MD.
Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA.

Background: In 2011, Glassberg et al. defined 4 common conditions in children with non- urinary tract dysfunction based on voiding symptoms and uroflow-electromyography (EMG) criteria: dysfunctional voiding (DV), idiopathic detrusor overactivity disorder (IDOD), detrusor underutilization disorder (DUD), and primary bladder neck dysfunction (PBND). We evaluated the inter-rater agreement on post hoc interpretation of uroflow-EMG studies using the Glassberg criteria.
Methods: Consecutive uroflow-EMG studies performed on children with non-neurogenic lower urinary tract dysfunction between 03/2013 and 05/2013 were collected. Studies with specific deficiencies were excluded (voided volume <30% of estimated bladder capacity, poor EMG lead contact, or urine spillage). After receiving a briefing on the Glassberg definitions, six raters (2 attending pediatric urologists, 2 pediatric urology fellows, 1 pediatric nephrologist, and 1 pediatric urology nurse practitioner) provided a post hoc assessment of each study as being characteristic of DV, IDOD, DUD, PBND, or normal/unclassifiable. Inter-rater agreement was analyzed by calculating Cohen’s kappa statistics.
Results: 66 Uroflow-EMG studies were included following exclusion of 40 studies with one or more deficiencies. The overall inter-rater agreement was moderate (kappa 0.46, 95% confidence interval 0.37 - 0.54). Agreement between individual observers ranged from fair to good (kappa 0.31-0.75). By diagnosis, inter-rater agreement ranged from fair (normal/unclassifiable, kappa 0.34) to moderate (DV, kappa 0.54).
Conclusion: Post hoc assessment of uroflow-EMG studies using the 2011 Glassberg definitions of DV, IDOD, DUD, and PBND may be limited by only moderate inter-rater agreement. In practice, diagnostic variability may result in suboptimal treatment choices for many patients. Inter-rater agreement could potentially be improved by development of standardized education modules regarding application of the Glassberg definitions.
>0.2Poor agreement
0.2-0.4Fair agreement
0.4-0.6Moderate agreement
0.6-0.8Good agreement
>0.8Very good agreement

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