DiVerences in observer variability of ultrasound measurements of the proximal and distal abdominal aorta
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1 14 J Med Screen 1998;5:14 18 DiVerences in observer variability of ultrasound measurements of the proximal and distal abdominal aorta HJCMPleumeekers, A W Hoes, P G H Mulder, E van der Does, A Hofman, J S Laméris, D E Grobbee Erasmus University Rotterdam, the Netherlands HJCMPleumeekers, assistant professor in general practice E van der Does, emeritus professor in general practice Julius Centre for Patient Oriented Research, Utrecht University, the Netherlands A W Hoes, associated professor in general practice D E Grobbee, professor in clinical epidemiology Department of Epidemiology and Biostatistics, Erasmus University Rotterdam, the Netherlands P G H Mulder, assistant professor in biostatistics A Hofman, professor in epidemiology Erasmus University Rotterdam, the netherlands J S Laméris, professor in radio diagnostics Correspondence to: DrHJCMPleumeekers, Department of General Practice, Erasmus University, Medical School, PO Box 1738, 3 DR Rotterdam, the Netherlands. Accepted for publication 1 March 1998 Abstract Objective To assess the observer variability of ultrasound measurements of the abdominal aorta and to study whether observer variability is influenced by the site of measurement or cardiovascular risk factors. Setting Population based screening programme for abdominal aortic aneurysms. Methods For 135 subjects taking part in a screening programme for abdominal aortic aneurysms, two of the three ultrasonographers measured the distal and proximal ultrasound diameter of the abdominal aorta, using B-mode ultrasound, according to the Rotterdam study scanning protocol. Results The mean diverence between two diverent observers was.6 mm (95% CI.15 to.27) for measurements of the distal aorta and.32 mm (95% CI.9 to.55) for the proximal aorta. Maximal differences between observers for measurements of both the distal and proximal aortic diameter were 4. mm. Interobserver variability in the proximal and distal measurements of the abdominal aorta was not related to the level of the major cardiovascular risk indicators. However, interobserver variability in ultrasound measurements of the proximal aorta increased with increasing waist circumference and increasing diameter of the proximal aorta. Conclusion Ultrasonographic readings of the distal and proximal aortic measurements can be interpreted within a range of plus or minus 3 mm. Ultrasound measurements are more accurate for the distal than for the proximal measurement. Definition of the aortic diameter based on a combination of both distal and proximal measurement may be more accurate. (J Med Screen 1998;5:14 18) Keywords: aneurysms; abdominal aorta; elderly Rupture of an aneurysm of the abdominal aorta is almost always fatal. 1 It is the cause of death in about 1% of men over 65 years of age in Western societies. 2 To prevent death from rupture, early detection and subsequent surgical repair is necessary. 3 Abdominal aortic aneurysms are diagnosed by palpation, radiography, aortography, computed tomography, and ultrasonography. 4 6 Ultrasonography is accepted as a practical and reliable method 7 and large scale ultrasonographic screening for aneurysms of the abdominal aorta has been advocated. 8 1 Interobserver variability in ultrasound measurements of the abdominal aorta may have consequences for screening practice and for clinical decision making. An increased variability in ultrasound measurement of the abdominal aorta may lead to erroneously diagnosed aneurysms but also to missing aneurysms during screening. Clinical decision making may be diycult because the decision whether elective surgery is indicated or not is considered if the aneurysm diameter has reached 5 mm, or, if the increase in aneurysm diameter is more than 5 mm over a period of six months. 4 Furthermore, it is important to assess whether interobserver variability in the ultrasound measurement of the aortic diameter is diverent in subgroups of patients. Increasing age, blood pressure, serum cholesterol concentrations or smoking may cause atherosclerotic changes in the aortic wall that may influence aortic diameter measurements. Variability in ultrasound measurements in subgroups may influence the relation between aortic diameter and these risk factors in epidemiological research, leading to erroneous conclusion. In the Rotterdam study, 14 a population based study among men and women aged 55 years or older, an ultrasound screening of the abdominal aorta is performed. This enabled us to assess the interobserver variation of ultrasound measurements of the proximal and distal abdominal aorta over a broad range of aortic diameters and to quantify the accuracy of ultrasound measurement of the abdominal aorta in relation to the aortic diameter. In addition, we studied interobserver variability in relation to various cardiovascular risk factors. Table 1 Selected characteristics of the 135 participants in the interobserver variability study. Values are means (standard deviations) Mean (SD) or proportion Age (years) 71 Female sex 61% Weight (kg) 72 (13) Height (cm) 166 (11) Waist circumference (cm) 92 (11) Diastolic BP (mm Hg) 73 (11) Systolic BP (mm Hg) 141 (23) Pulse (beats/minute) 74 (11) Smoking (pack years) 34 (19) Serum cholesterol (mmol/l) 6.4 (1.2) Serum HDL cholesterol (mmol/l) 1.33 (.35) Distal aortic diameter (mm) 19.6 (9.3) Proximal aortic diameter (mm) 19.9 (9.) BP = Blood pressure, HDL = high density lipoprotein.
2 Observer variability of ultrasound measurements of the abdominal aorta 15 Measurement 2 (mm) Measurement 2 (mm) A B 1 Percentage Diameter (mm) Figure 1 The distribution of the distal aortic diameter (mm) in 135 participants aged 55 years or older. Methods All participants were selected from the Rotterdam study, a prospective follow up study of 7983 subjects aged 55 years or over living in Ommoord, a suburb of Rotterdam. Rationale and design of this study are described in detail elsewhere. 14 As part of the Rotterdam study participants had an ultrasound examination of the abdominal aorta. Ultrasound data of 5283 participants are available. The overall response rate of the study is 78%. To obtain a broad spectrum of aortic diameters, 135 participants with diverent aortic diameters were selected for duplicated measurements. Ultrasound recordings were made using a 3.5 MHZ linear array probe (Toshiba SSH Measurement 1 (mm) Measurement 1 (mm) Figure 2 Correlation between two consecutive measurements by two diverent observers of the distal (A) and proximal (B) aortic diameter in 135 participants of the Rotterdam study. The line represents identical results for the two observers. (Intraclass correlation coeycients are.998 and.995 respectively) A). Food was not restricted before the ultrasound recordings, which were made with the patient in supine position. No adjustments for blood pressure variations were made. Diameters were measured between the two most outer wall echo in the anteroposterior plane. Firstly, a longitudinal scan of the abdominal aorta was made and the diameter of the widest part of the most distant section of the abdominal aorta was recorded (distal diameter). The diameter of the aorta was also measured at the level of the superior mesenteric artery (proximal diameter). An aneurysm was considered present if the distal aortic diameter was 35 mm or more, or, if the distal aortic diameter increased by more than 5% compared with the proximal diameter. For this, recordings and measurements were made by three technical assistants, who were trained especially for the project. Of all possible sources of measurement imprecision, interobserver variability may constitute a large contribution to the variability in ultrasonographic measurements of the abdominal aorta. As we focused on interobserver variability as an important cause of variability in ultrasound measurements of the abdominal aorta, the time between two measurements was kept as short as possible to minimise the influence of biological variation over time. To assess the interobserver variability of measurements of the proximal and distal diameter of the abdominal aorta, duplicate measurements were performed in 135 participants of the Rotterdam study. The second measurement was made within a few minutes after the first measurement by one of the other trained technical assistants, who was not aware of the results of the first measurement. Thus, three groups of paired measurements were formed by the three sonographers (SS, IH, and IB). Because of technical reasons two of the three sonographer pairs could not complete the number of 5 measurements that were initially planned. At the end of the study, observer pair 1 had performed 5 paired measurements, while the corresponding numbers for pair 2 and pair 3 were 38 and 47, respectively. The duplicated measurements were plotted against each other and intraclass correlation coeycients were calculated. 15 Because a high level of correlation does not necessarily imply a clinically acceptable level of agreement between two measurements, we also calculated the mean diverences, with standard errors and 95% confidence intervals between measurements. The limits of agreement were calculated according to Bland and Altman 11 as the mean (±2SD) diverence between two observers. We also estimated the correlation of the absolute diverence between consecutive measurements and the true aortic diameter (estimated as the mean of the two consecutive measurements in one subject) to assess whether interobserver variability increased with increasing aortic diameter. The Spearman rank correlation coeycient was calculated. Several cardiovascular risk indicators were measured to discover if the levels of these
3 16 Pleumeekers, Hoes, Mulder, et al Table 2 Results of consecutive measurements by two diverent observers of the proximal and distal diameter of the abdominal aorta Observer pair n Abs mean diverence (mm) SD of the mean (mm) r 95% CI Distal diameter I to II to III to Total to Proximal diameter I to II to.7 4. III to.6 3. Total to Maximal abs div (mm) I (Observer 1 v observer 2), II (observer 1 v observer 3), III (observer 2 v observer 3). Abs mean div = absolute mean diverence between the two observers (mm), r = intraclass correlation coeycient, maximal abs div = maximal absolute diverence between the two observers (mm). Measurement error (mm) Measurement error (mm) A B True distal aortic diameter (mm) True proximal aortic diameter (mm) Figure 3 (A) Correlation of the absolute diverence between two consecutive measurements of the distal aortic diameter by two diverent observers (measurement error) and the true distal aortic diameter (that is, average of two diverent measurements), in 135 participants (Spearman rank correlation r=.1; p=.9). (B) Correlation of the absolute diverence between two consecutive measurements of the proximal aortic diameter by two diverent observers (measurement error) and the true proximal aortic diameter (that is, average of two diverent measurements), in 135 participants (Spearman rank correlation r=.; p <.1). 7 8 cardiovascular risk indicators influenced interobserver variability. Blood pressure was measured in sitting position with a random-zero sphygmomanometer. The average of two consecutive measurements was used to calculate the diastolic and systolic blood pressure. Nonfasting blood samples were collected to determine serum total cholesterol using an automated enzymatic procedure. 13 High density lipoprotein was measured after precipitation of the non-hdl fraction with phosphotungstatemagnesium. Waist circumference was measured to detect a possible interference of bowel gas and fat between the transducer and the aorta with the diameter measurements. To determine the influence of the level of several cardiovascular risk indicators on measurement imprecision, Spearman rank correlations of the absolute diverence between the two consecutive measurements and the level of cardiovascular risk indicators of each participant were calculated. Statistical analyses were performed using BMDP software. Results Table 1 gives selected characteristics of the 135 participants in the study. The mean distal aortic diameter is 19.6 mm and ranges from 12 mm to 82 mm. The mean proximal aortic diameter is 19.9 mm and ranges from 14 mm to 62 mm. Figure 1 shows the distribution of the distal aortic diameter. The duplicated measurements of the distal (fig 2A) and the proximal (fig 2B) aortic diameters are plotted against each other for the 135 participants. The intraclass correlation coeycient for the duplicated measurements of the distal aortic diameter was.998 and varied from.994 to.999 for the diverent observer pairs (table 2). For the proximal aortic diameter, the intraclass correlation coeycient was.995 and varied from.993 to.999 between the observer pairs. The maximum diverence between duplicated measurements by two diverent observers was 4 mm with a mean diverence of.6 mm (95% CI.15 to.27) for the distal aorta. The maximum diverence for the proximal aorta was also 4 mm, but the mean diverence between these measurements was.32 mm (95% CI.9 to.55). The mean diverences between the diverent observers were small, ranging from.6 to.8 mm in distal readings and from.21 to.42 mm in the proximal readings. In the distal measurements the mean diverence between two diverent observers did not statistically diver from zero in all the three observer pairs. In the proximal measurement, however, a statistically significant diverence (p<.5) between the first and second observer was present. In addition the limits of agreement were calculated as the mean (±2SD). The limits of agreement varied from 2.78 to 2.9 mm in the distal measurement and from 2.48 to 3.32 mm in the proximal measurement. Figure 3 gives the association between the absolute mean diverences between the first and second measurement and the estimated true distal and proximal aortic diameters. An increase in measurement imprecision with increasing true aortic diameter seemed to be present for the proximal measurement of the aorta (Spearman rank correlation coeycient r=.; p=.2). Exclusion of one participant with an extremely large diameter of 8 mm did not change these findings. No influence of the
4 Observer variability of ultrasound measurements of the abdominal aorta 17 true diameter on measurement imprecision in the distal aorta was demonstrated (Spearman r=.1; p=.9). The absolute diverence between duplicated measurements of both the distal and proximal aortic diameter appeared not to be influenced by age, sex, smoking habits, systolic and diastolic blood pressure, serum total and HDL cholesterol values. However, a larger waist circumference was associated with an increase in measurement imprecision of the ultrasound measurement of the proximal diameter of the abdominal aorta (Spearman r=.24; p<.1). Discussion In this population based study among 135 subjects aged 55 years or older, the interobserver variability of ultrasound measurements of the distal part of the abdominal aorta, measured as the comparability of paired measurements by two diverent observers, was generally low and never more than 4 mm. The interobserver variability of the ultrasonographic measurements of the proximal aorta was higher, never exceeded 4 mm, and increased with an increase in the diameter of the aorta and with an increasing waist circumference. No relation between various cardiovascular risk factors and interobserver variability was found. In some other studies interobserver variability of ultrasound measurements of the abdominal aorta has been examined These studies, however, are mostly confined to ultrasound measurements in abdominal aortic aneurysms and do not cover a broad range of aortic diameters and for that reason the conclusions are not always able to be generalised to ultrasound measurements in screening. Ellis and coworkers 18 studied 1 subjects with an abdominal aneurysm and reported an interobserver variability in the distal measurement of 8 mm. Yucel and coworkers 17 concluded, from a study among 28 patients, that diverences in ultrasound measurements of the distal aorta between two observers of less than 5 mm could be the result of interobserver variability. Thomas and coworkers studied interobserver variability in ultrasound measurements of the distal aorta in 3 patients. They could not demonstrate diverences between two sonographers resulting from measurement imprecision. On the other hand Jaakkola and coworkers 21 found in repeated ultrasound measurements of the aortic diameters a diverence in 11% of them between ultrasound measurements of 5 mm or more. Our finding that interobserver variability of distal measurement of the abdominal aorta is low, is in contrast with these latter findings. In view of our estimated limits of agreement of ultrasound measurements of the distal aorta, we find that diverences between measurements of two observers of more than 3 mm cannot be the result of interobserver variability. For clinical practice this amount of variability must be reassuring because aneurysm surgery is only recommended if the aneurysm increases by more than 5 mm in six months or has reached 5 mm or more in diameter. None of the earlier studies assessed interobserver variability in the proximal measurements. As there is a considerable variation in the normal aortic diameter, we used the proximal diameter of the abdominal aorta as a reference to calculate a relative increase in the size of the distal part of the abdominal aorta. In our study interobserver variability in the proximal measurement is relatively high if compared with the distal measurements and increases with increasing waist circumference. The finding that with increasing true proximal aortic diameter the interobserver variability of the proximal aorta increases, is another indication of the potential imprecision in ultrasonographic measurements of the proximal part of the abdominal aorta. This imprecision in the proximal measurement may be because of difficulties in imaging the proximal part compared with the distal part of the abdominal aorta. Our sonographers were well trained and gained substantial experience in ultrasonographic techniques, but locating the mesenteric superior artery can be a problem, especially when the imaging is diycult because of gas in the stomach or colon. However, combining the results of the distal and proximal measurement when doubts exist as to whether an aneurysm is present, may increase accuracy of the ultrasound measurement and also takes into account diverences in the normal aortic diameters. If aneurysm is diagnosed in this way false positive and false negative results may be limited to a minimum. We conclude that ultrasonographic assessment of the aortic diameter in a screening programme for abdominal aortic aneurysms can be accurate when in experienced hands and performed according to a strict protocol. Ultrasonographic readings of the distal and proximal aortic measurements can be interpreted within a range of plus or minus 3 mm. Giving the diverences in observer variability between diverent studies, assessment of interobserver variability of ultrasound measurements should be part of quality maintenance in a screening programme for abdominal aortic aneurysms. 1 Castleden WH, Mercer JC. Abdominal aortic aneurysms in western Australia: descriptive epidemiology and patterns of rupture. Br J Surg 1985;72: Johansson G, Swedenborg J. Ruptured abdominal aortic aneurysms: a study of incidence and mortality. Br J Surg 1986;73: Strachan DP. Predictors of death from aortic aneurysm among middle-aged men: the Whitehall study. Br J Surg 1991;78: Scott RAP, Wilson NM, Aston HA, et al. Is surgery necessary for abdominal aortic aneurysm less than 6 cm in diameter? Lancet 1993;342: Geroulakos G, Nicolaides A. Infrarenal abdominal aortic aneurysms less than five centimetres in diameter: the surgeon s dilemma. Eur J Vasc Surg 1992;6: Grimshaw GM, Thompson KM, Hamer JD. A statistical analysis of growth of small abdominal aortic aneurysms. Eur J Vasc Surg 1994;8: Wilmink AB, Hubbard CS, Quick CR. Quality of measurements of the infrarenal aortic diameter by ultrasound. J Med Screen 1997;4: Khoo DE. Ashton H. Scott RA. Is screening once at age 65 an evective method for detection of abdominal aortic aneurysms? J Med Screen 1994;1: Lucarotti M, Shaw F, Poskitt K, et al. The Gloucestershire aneurysm screening programme: the first 2 years expierence. Eur J Vasc Surg 1993;7: Harris PL. Reducing the mortality from abdominal aortic aneurysms: need for a national screening program. BMJ 1992;35:697 9.
5 18 Pleumeekers, Hoes, Mulder, et al 11 Bland JM, Altman DG. Statistical methods for assessing agreement between two methods of clinical measurement. Lancet 1986;335: Anonymous. Measurement imprecision: ignore or investigate. Lancet 1992;339: Vangent CM, Vandervoort HA, Bruyn AM de, et al. Cholesterol determinations. A comparative study of methods with special reference to enzymatic procedures. Clin Chim Acta 1977;75: Hofman A, Grobbee DE, Jong PTVM de, et al. Determinants of disease and disability in the elderly: the Rotterdam Elderly Study. Eur J Epidemiol 1991;7: Armitage P. Statistical methods in medical research. New York: Wiley, Brennan P, Silman A. Statistical methods for assessing variability in clinical measures. BMJ 1992;34: Yucel KE, Fillmore DJ, Knox TA, et al. Sonographic measurement of abdominal aortic diameter: interobserver variability. J Ultrasound Med 1991;1: Ellis M, Powell JT, Greenhalgh RM. Limitations of ultrasonography in surveillance of small abdominal aortic aneurysms. Br J Surg 1991;78: Akkersdijk GJM, Puylaert BCM, Coerkamp EG, et al. Accuracy of ultrasonographic measurement of infrarenal abdominal aortic aneurysm. Br J Surg 1994;81:372. Thomas PRS, Shaw JC, Ashton HA, et al. Accuracy of ultrasound in a screening program for abdominal aortic aneurysms. J Med Screen 1994;1: Jaakkola P, Hippelainen M, Farin P, et al. Interobserver variability in measuring the dimensions of the abdominal aorta: comparison of ultrasound and computed tomography. Eur J Vasc Endovasc Surg 1996;12: th Conference of the International Health Evaluation Association 28 3 September 1998, The Royal College of Physicians, London This IHEA conference entitled New opportunities for prevention: developing practical approaches will consider the following topics: + Advances in screening + Developing informatics + Pharmaceutical interventions + Target setting + Health in the workplace + Behavioural interventions Further details: Profile Productions, Northumberland House, 11 The Pavement, Popes Lane, London W5 4NG. Tel: +44 () Fax: +44 ()
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