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{
    "pk": 53012,
    "title": "Assessment of Inter-rater Variability in the Diagnosis of Urinary Tract Infections in the Emergency Department",
    "subtitle": null,
    "abstract": "<p><strong>Introduction:</strong> Urinary tract infections (UTI) are among the most common bacterial infections diagnosed in the emergency department (ED), yet the urinalysis results can be neither sensitive nor specific for UTI. Our objective was to quantify inter-rater variability of three emergency attending physicians for the clinical diagnosis of UTI, and secondarily to compare the diagnosis made at bedside by the treating clinician with the evaluations of three emergency physician-chart reviewers after the fact.</p>\n<p><strong>Methods:</strong> Chart reviewers read 18 articles on the diagnosis of UTI before retrospectively evaluating a convenience sample of 473 ED encounters where patients received both a urinalysis and urine culture as part of their ED evaluation. The chart reviewers were blinded to the urine culture results, medications administered and prescribed, and to the treating clinician’s diagnoses. Reviewers were asked to rate the likelihood of UTI based on a 0-4 ordinal scale. A “true positive” UTI occurred when the treating clinician diagnosed the patient with a UTI and the urine culture had ≥10,000 colony-forming units (CFU)/mL of bacteria. We considered a “false positive” to be when the treating clinician diagnosed the patient with a UTI, but the urine culture was &lt; 10,000 CFU/mL of bacteria. A “true negative” occurred when the treating clinician did not diagnose the patient with a UTI, and the urine culture was &lt; 10,000 CFU/mL of bacteria.</p>\n<p><strong>Results: </strong>Median patient age was 63 years, 355 (75%) were female sex, 409 (86.5%) were White race, and 207 were admitted to the hospital. The inter-rater agreement among the three independent reviewers was high (κ 0.82-0.85) with intraclass coefficient (2,1) = 0.83. However, the reviewers-to-treating clinician agreement was only moderate in the true positives (treating clinician diagnosed patient with a UTI and the patient had a positive urine culture) and lowest in the false positives (treating clinician diagnosed the patient with a UTI, but the urine culture was &lt; 10,000 CFU/mL with κ values of 0.44 and 0.21, respectively). The variables associated with consensus among reviewers were nitrites, leukocyte esterase, and higher urine white blood cells.</p>\n<p><strong>Conclusion: </strong>There was high consensus among reviewers about the likelihood of a urinary tract infection, but lower consensus when comparing reviewers’ impressions with those of the treating clinician. At bedside emergency clinicians were more likely to diagnose a UTI with a resultant negative urine culture. Further research is needed to improve the diagnostic accuracy of UTI in the emergency department.</p>",
    "language": "eng",
    "license": {
        "name": "Creative Commons Attribution 4.0",
        "short_name": "CC BY 4.0",
        "text": "Attribution — You must give appropriate credit, provide a link to the license, and indicate if changes were made. You may do so in any reasonable manner, but not in any way that suggests the licensor endorses you or your use.\r\n\r\nNo additional restrictions — You may not apply legal terms or technological measures that legally restrict others from doing anything the license permits.",
        "url": "https://creativecommons.org/licenses/by/4.0"
    },
    "keywords": [
        {
            "word": "urinary tract infection (UTI)"
        },
        {
            "word": "inter-rater reliability (IRR)"
        },
        {
            "word": "Emergency Department (ED)"
        },
        {
            "word": "concordance"
        },
        {
            "word": "discordance"
        },
        {
            "word": "Diagnosis"
        },
        {
            "word": "urinalysis"
        },
        {
            "word": "Urinary Tract Infection"
        },
        {
            "word": "Urine Culture"
        }
    ],
    "section": "Original Research (Limit 4000 words)",
    "is_remote": false,
    "remote_url": null,
    "frozenauthors": [
        {
            "first_name": "Johnathan",
            "middle_name": "M",
            "last_name": "Sheele",
            "name_suffix": "",
            "institution": "Mayo Clinic, Department of Emergency Medicine, Jacksonville, Florida",
            "department": ""
        },
        {
            "first_name": "Jesse",
            "middle_name": "W",
            "last_name": "St Clair IV",
            "name_suffix": "",
            "institution": "Mayo Clinic, Department of Emergency Medicine, Jacksonville, Florida",
            "department": ""
        },
        {
            "first_name": "Edward",
            "middle_name": "J",
            "last_name": "Ziegler",
            "name_suffix": "",
            "institution": "Mayo Clinic Alix School of Medicine, Jacksonville, Florida",
            "department": ""
        },
        {
            "first_name": "Michael",
            "middle_name": "M",
            "last_name": "Mohseni",
            "name_suffix": "",
            "institution": "Mayo Clinic, Department of Emergency Medicine, Jacksonville, Florida",
            "department": ""
        }
    ],
    "date_submitted": "2025-10-02T20:45:28.534000Z",
    "date_accepted": "2025-12-22T22:21:38.141000Z",
    "date_published": "2026-04-02T17:54:00Z",
    "render_galley": null,
    "galleys": [
        {
            "label": "PDF",
            "type": "pdf",
            "path": "https://journalpub.escholarship.org/westjem/article/53012/galley/49336/download/"
        }
    ]
}