Document Detail

Is the NIHSS certification process too lenient?
MedLine Citation:
PMID:  19295205     Owner:  NLM     Status:  MEDLINE    
BACKGROUND AND PURPOSE: The National Institutes of Health Stroke Scale (NIHSS) is a widely used measure of neurological function in clinical trials and patient assessment; inter-rater scoring variability could impact communications and trial power. The manner in which the rater certification test is scored yields multiple correct answers that have changed over time. We examined the range of possible total NIHSS scores from answers given in certification tests by over 7,000 individual raters who were certified. METHODS: We analyzed the results of all raters who completed one of two standard multiple-patient videotaped certification examinations between 1998 and 2004. The range for the correct score, calculated using NIHSS 'correct answers', was determined for each patient. The distribution of scores derived from those who passed the certification test then was examined. RESULTS: A total of 6,268 raters scored 5 patients on Test 1; 1,240 scored 6 patients on Test 2. Using a National Stroke Association (NSA) answer key, we found that correct total scores ranged from 2 correct scores to as many as 12 different correct total scores. Among raters who achieved a passing score and were therefore qualified to administer the NIHSS, score distributions were even wider, with 1 certification patient receiving 18 different correct total scores. CONCLUSIONS: Allowing multiple acceptable answers for questions on the NIHSS certification test introduces scoring variability. It seems reasonable to assume that the wider the range of acceptable answers in the certification test, the greater the variability in the performance of the test in trials and clinical practice by certified examiners. Greater consistency may be achieved by deriving a set of 'best' answers through expert consensus on all questions where this is possible, then teaching raters how to derive these answers using a required interactive training module.
Nancy K Hills; S Andrew Josephson; Patrick D Lyden; S Claiborne Johnston
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Publication Detail:
Type:  Evaluation Studies; Journal Article; Research Support, N.I.H., Extramural     Date:  2009-03-19
Journal Detail:
Title:  Cerebrovascular diseases (Basel, Switzerland)     Volume:  27     ISSN:  1421-9786     ISO Abbreviation:  Cerebrovasc. Dis.     Publication Date:  2009  
Date Detail:
Created Date:  2009-05-01     Completed Date:  2009-07-22     Revised Date:  2010-09-23    
Medline Journal Info:
Nlm Unique ID:  9100851     Medline TA:  Cerebrovasc Dis     Country:  Switzerland    
Other Details:
Languages:  eng     Pagination:  426-32     Citation Subset:  IM    
Copyright Information:
Copyright 2009 S. Karger AG, Basel.
Stroke Sciences Group, Department of Neurology, University of California, San Francisco, CA 94143-0114, USA.
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MeSH Terms
Certification / standards*
Clinical Competence / standards*
Diagnostic Tests, Routine
Education / standards
National Institutes of Health (U.S.)*
Reproducibility of Results
Severity of Illness Index*
Stroke / diagnosis*,  physiopathology*
United States
Grant Support

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