Reliability and Validity of Estimating the NIH Stroke Scale Score from Medical Records Scott E.

Kasner, MD; Julio A. Chalela, MD; Jean M. Luciano, RN; Brett L. Cucchiara, MD; Eric C. Raps, MD; Michael L. McGarve , MD; Moll B. Conro , MD; A. Russell Localio, MS Background and Purpose!"he ai# o$ our stu% &as to %eter#ine &hether the National 'nstitutes o$ (ealth Stro)e Scale *N'(SS+ can ,e esti#ate% retrospectivel $ro# #e%ical recor%s. "he N'(SS is a -uantitative #easure o$ stro)e.relate% neurolo/ical %e$icit &ith esta,lishe% relia,ilit an% vali%it $or use in prospective clinical research. Recentl , retrospective o,servational stu%ies have esti#ate% N'(SS scores $ro# #e%ical recor%s $or -uantitative outco#e anal sis. "he relia,ilit an% vali%it o$ esti#ation ,ase% on chart revie& has not ,een %eter#ine%. Methods!"hirt .nine patients &ere selecte% ,ecause their N'(SS scores &ere $or#all #easure% at a%#ission an% %ischar/e. (an%&ritten notes $ro# #e%ical recor%s &ere a,stracte% an% N'(SS scores &ere esti#ate% , 0 raters &ho &ere ,lin%e% to the actual scores. Esti#ate% scores &ere co#pare% a#on/ raters an% &ith the actual #easure% scores. Results!'nterrater relia,ilit &as e1cellent, &ith an intraclass correlation coe$$icient o$ 2.34. Scores &ere &ell cali,rate% a#on/ the 0 raters. Esti#ate% N'(SS scores closel appro1i#ate% the actual scores, &ith a pro,a,ilit o$ 2.30 o$ correctl ran)in/ a set o$ patients accor%in/ to 5.point interval cate/ories *as %eter#ine% , the area un%er the receiver.operator characteristic curve+. 6atients &ith e1cellent outco#es *N'(SS score o$ 75+ coul% ,e i%enti$ie% &ith sensitivit o$ 2.84 an% speci$icit o$ 2.39. "here &ere no si/ni$icant %i$$erences ,et&een these para#eters at a%#ission an% %ischar/e. Conclusions!:or the purposes o$ retrospective stu%ies o$ acute stro)e outco#e, the N'(SS can ,e a,stracte% $ro# #e%ical recor%s &ith a hi/h %e/ree o$ relia,ilit an% vali%it . (Stroke. 1999 !"#1$!%&1$!'.( )ey *ords# neurops cholo/ical tests n outco#e assess#ent n repro%uci,ilit o$ results Clinical outco#es a$ter stro)e are #easure% -uantitativel in clinical trials ,ut are o$ten recor%e% onl -ualitativel in clinical practice. Retrospective stro)e stu%ies that rel on chart revie& are there$ore li#ite% to clinical narratives o$ the neurolo/ical e1a#ination that are %i$$icult to utili;e in $or#al

%ata anal ses an% co#pare to pu,lishe% %ata. "he National 'nstitutes o$ (ealth Stro)e Scale *N'(SS+ is a -uantitative #easure o$ stro)e.relate% neurolo/ical %e$icit that spans )e aspects o$ the neurolo/ical e1a#ination< level o$ consciousness, lan/ua/e $unction, ne/lect, visual $iel%s, e e #ove#ents, $acial s ##etr , #otor stren/th, sensation, an% coor%ination.=,4 "he e1a#ination can ,e per$or#e% -uic)l , an% the N'(SS score can ,e assesse% , neurolo/ists an% nonneurolo/ists a$ter appropriate trainin/.> "he scale has proven intrarater an% interrater relia,ilit an% has pre%ictive vali%it $or stro)e outco#e.4,? Conse-uentl , the N'(SS is use% in nearl ever current acute stro)e stu% in the @nite% States as a #easure o$ the initial an% $inal neurolo/ical %e$icit. Because o$ the &i%esprea% support $or the N'(SS, recent retrospective stu%ies have esti#ate% the N'(SS $ro# #e%ical recor%s to -uanti$ ,aseline %e$icits an% outco#es.5,0 Athers have avoi%e% this approach8 ,ecause o$ concerns that the relia,ilit an% vali%it o$ score esti#ation has not ,een prove%, an% the interpretation o$ such retrospective stu%ies #a ,e li#ite% , the #etho%olo/ical constraints o$ in$or#ation ,ias. Be evaluate% the a,ilit to e1tract the N'(SS score $ro# #e%ical recor%s. S+b,ects and Methods "his stu% &as per$or#e% at an aca%e#ic universit hospital a$ter revie& an% approval , our institutional revie& ,oar%. 6atients &ere selecte% $or this stu% i$ the ha% su$$ere% an acute ische#ic stro)e lea%in/ to enroll#ent in an e1peri#ental stro)e protocol. "o ,e inclu%e%, patients #ust have ha% a $or#al #easure#ent o$ the N'(SS score *as part o$ the e1peri#ental stro)e protocol+ at the ti#e o$ a%#ission an% %ischar/e. At our center, this in$or#ation &as collecte% prospectivel %urin/ > separate clinical trials, provi%in/ >9 patients $or anal sis. "he #e%ical #onitors $or these clinical trials per#itte% the use o$ their case report $or#s to %eter#ine the actual N'(SS scores $or this stu% . :or each eli/i,le patient, the han%&ritten notes $ro# the %a o$ a%#ission an% the %a o$ %ischar/e &ere photocopie%, e%ite% to re#ove an re$erence to the actual #easure% N'(SS score an% participation in the clinical trial, an% then photo.