Diagnostic accuracy of a clinical diagnosis of idiopathic pulmonary fibrosis: an international case–cohort study
Identifieur interne : 002472 ( Pmc/Corpus ); précédent : 002471; suivant : 002473Diagnostic accuracy of a clinical diagnosis of idiopathic pulmonary fibrosis: an international case–cohort study
Auteurs : Simon L. F. Walsh ; Toby M. Maher ; Martin Kolb ; Venerino Poletti ; Richard Nusser ; Luca Richeldi ; Carlo Vancheri ; Margaret L. Wilsher ; Katerina M. Antoniou ; Jüergen Behr ; Elisabeth Bendstrup ; Kevin Brown ; Lucio Calandriello ; Tamera J. Corte ; Vincent Cottin ; Bruno Crestani ; Kevin Flaherty ; Ian Glaspole ; Jan Grutters ; Yoshikazu Inoue ; Maria Kokosi ; Yasuhiro Kondoh ; Vasileios Kouranos ; Michael Kreuter ; Kerri Johannson ; Eoin Judge ; Brett Ley ; George Margaritopoulos ; Fernando J. Martinez ; Maria Molina-Molina ; Ant Nio Morais ; Hilario Nunes ; Ganesh Raghu ; Christopher J. Ryerson ; Moises Selman ; Paolo Spagnolo ; Hiroyuki Taniguchi ; Sara Tomassetti ; Dominique Valeyre ; Marlies Wijsenbeek ; Wim Wuyts ; David Hansell ; Athol WellsSource :
- The European Respiratory Journal [ 0903-1936 ] ; 2017.
Abstract
We conducted an international study of idiopathic pulmonary fibrosis (IPF) diagnosis among a large group of physicians and compared their diagnostic performance to a panel of IPF experts.
A total of 1141 respiratory physicians and 34 IPF experts participated. Participants evaluated 60 cases of interstitial lung disease (ILD) without interdisciplinary consultation. Diagnostic agreement was measured using the weighted kappa coefficient (κw). Prognostic discrimination between IPF and other ILDs was used to validate diagnostic accuracy for first-choice diagnoses of IPF and were compared using the C-index.
A total of 404 physicians completed the study. Agreement for IPF diagnosis was higher among expert physicians (κw=0.65, IQR 0.53–0.72, p<0.0001) than academic physicians (κw=0.56, IQR 0.45–0.65, p<0.0001) or physicians with access to multidisciplinary team (MDT) meetings (κw=0.54, IQR 0.45–0.64, p<0.0001). The prognostic accuracy of academic physicians with >20 years of experience (C-index=0.72, IQR 0.0–0.73, p=0.229) and non-university hospital physicians with more than 20 years of experience, attending weekly MDT meetings (C-index=0.72, IQR 0.70–0.72, p=0.052), did not differ significantly (p=0.229 and p=0.052 respectively) from the expert panel (C-index=0.74 IQR 0.72–0.75).
Experienced respiratory physicians at university-based institutions diagnose IPF with similar prognostic accuracy to IPF experts. Regular MDT meeting attendance improves the prognostic accuracy of experienced non-university practitioners to levels achieved by IPF experts.
Url:
DOI: 10.1183/13993003.00936-2017
PubMed: 28860269
PubMed Central: 5593374
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PMC:5593374Le document en format XML
<record><TEI><teiHeader><fileDesc><titleStmt><title xml:lang="en">Diagnostic accuracy of a clinical diagnosis of idiopathic pulmonary fibrosis: an international case–cohort study</title><author><name sortKey="Walsh, Simon L F" sort="Walsh, Simon L F" uniqKey="Walsh S" first="Simon L. F." last="Walsh">Simon L. F. Walsh</name><affiliation><nlm:aff id="af1">Dept of Radiology, King's College Hospital Foundation Trust, London, UK</nlm:aff></affiliation></author><author><name sortKey="Maher, Toby M" sort="Maher, Toby M" uniqKey="Maher T" first="Toby M." last="Maher">Toby M. Maher</name><affiliation><nlm:aff id="af2">Dept of Respiratory Medicine, Interstitial Lung Disease Unit, Royal Brompton Hospital and National Heart and Lung Institute, Imperial College, London, UK</nlm:aff></affiliation></author><author><name sortKey="Kolb, Martin" sort="Kolb, Martin" uniqKey="Kolb M" first="Martin" last="Kolb">Martin Kolb</name><affiliation><nlm:aff id="af3">Depts of Medicine and Pathology/Molecular Medicine, McMaster University, Firestone Institute for Respiratory Health, Hamilton, ON, Canada</nlm:aff></affiliation></author><author><name sortKey="Poletti, Venerino" sort="Poletti, Venerino" uniqKey="Poletti V" first="Venerino" last="Poletti">Venerino Poletti</name><affiliation><nlm:aff id="af4">Department of Diseases of the Thorax, Ospedale GB Morgagni, Forlì, Italy</nlm:aff></affiliation><affiliation><nlm:aff id="af5">Dept of Respiratory Diseases and Allergy, Aarhus University Hospital, Aarhus, Denmark</nlm:aff></affiliation></author><author><name sortKey="Nusser, Richard" sort="Nusser, Richard" uniqKey="Nusser R" first="Richard" last="Nusser">Richard Nusser</name><affiliation><nlm:aff id="af6">Dept of Respiratory Medicine, Summit Hospital, Oakland, CA, USA</nlm:aff></affiliation></author><author><name sortKey="Richeldi, Luca" sort="Richeldi, Luca" uniqKey="Richeldi L" first="Luca" last="Richeldi">Luca Richeldi</name><affiliation><nlm:aff id="af7">Unità Operativa Complessa di Pneumologia, Università Cattolica del Sacro Cuore, Fondazione Policlinico A. Gemelli, Rome, Italy</nlm:aff></affiliation></author><author><name sortKey="Vancheri, Carlo" sort="Vancheri, Carlo" uniqKey="Vancheri C" first="Carlo" last="Vancheri">Carlo Vancheri</name><affiliation><nlm:aff id="af8">Dept of Clinical and Experimental Medicine, University of Catania, University - Hospital “Policlinico - Vitt. Emanuele”, Catania, Italy</nlm:aff></affiliation></author><author><name sortKey="Wilsher, Margaret L" sort="Wilsher, Margaret L" uniqKey="Wilsher M" first="Margaret L." last="Wilsher">Margaret L. Wilsher</name><affiliation><nlm:aff id="af9">Auckland District Health Board and the University of Auckland, Auckland, New Zealand</nlm:aff></affiliation></author><author><name sortKey="Antoniou, Katerina M" sort="Antoniou, Katerina M" uniqKey="Antoniou K" first="Katerina M." last="Antoniou">Katerina M. Antoniou</name><affiliation><nlm:aff id="af10">Dept of Respiratory Medicine, Faculty of Medicine, University of Crete, Heraklion, Greece</nlm:aff></affiliation></author><author><name sortKey="Behr, Juergen" sort="Behr, Juergen" uniqKey="Behr J" first="Jüergen" last="Behr">Jüergen Behr</name><affiliation><nlm:aff id="af11">Dept of Medicine V, University of Munich and Asklepios Fachkliniken Gauting, Comprehensive Pneumology Center, member of the German Center for Lung Research, Munich, Germany</nlm:aff></affiliation></author><author><name sortKey="Bendstrup, Elisabeth" sort="Bendstrup, Elisabeth" uniqKey="Bendstrup E" first="Elisabeth" last="Bendstrup">Elisabeth Bendstrup</name><affiliation><nlm:aff id="af5">Dept of Respiratory Diseases and Allergy, Aarhus University Hospital, Aarhus, Denmark</nlm:aff></affiliation></author><author><name sortKey="Brown, Kevin" sort="Brown, Kevin" uniqKey="Brown K" first="Kevin" last="Brown">Kevin Brown</name><affiliation><nlm:aff id="af12">National Jewish Health, Denver, CO, USA</nlm:aff></affiliation></author><author><name sortKey="Calandriello, Lucio" sort="Calandriello, Lucio" uniqKey="Calandriello L" first="Lucio" last="Calandriello">Lucio Calandriello</name><affiliation><nlm:aff id="af13">Institute of Radiology, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario A. Gemelli, Rome, Italy</nlm:aff></affiliation></author><author><name sortKey="Corte, Tamera J" sort="Corte, Tamera J" uniqKey="Corte T" first="Tamera J." last="Corte">Tamera J. Corte</name><affiliation><nlm:aff id="af14">Dept of Respiratory Medicine, Royal Prince Alfred Hospital, and University of Sydney, Sydney, Australia</nlm:aff></affiliation></author><author><name sortKey="Cottin, Vincent" sort="Cottin, Vincent" uniqKey="Cottin V" first="Vincent" last="Cottin">Vincent Cottin</name><affiliation><nlm:aff id="af15">Service de Pneumologie, Hopital L. Pradel, Lyon, France</nlm:aff></affiliation></author><author><name sortKey="Crestani, Bruno" sort="Crestani, Bruno" uniqKey="Crestani B" first="Bruno" last="Crestani">Bruno Crestani</name><affiliation><nlm:aff id="af16">APHP, Hopital Bichat, Service de Pneumologie A, Université Paris Diderot, Paris, France</nlm:aff></affiliation></author><author><name sortKey="Flaherty, Kevin" sort="Flaherty, Kevin" uniqKey="Flaherty K" first="Kevin" last="Flaherty">Kevin Flaherty</name><affiliation><nlm:aff id="af17">University of Michigan, Division of Pulmonary and Critical Care Medicine, Ann Arbor, MI, USA</nlm:aff></affiliation></author><author><name sortKey="Glaspole, Ian" sort="Glaspole, Ian" uniqKey="Glaspole I" first="Ian" last="Glaspole">Ian Glaspole</name><affiliation><nlm:aff id="af18">Alfred Health - Allergy, Immunology and Respiratory Medicine, Melbourne, Australia</nlm:aff></affiliation></author><author><name sortKey="Grutters, Jan" sort="Grutters, Jan" uniqKey="Grutters J" first="Jan" last="Grutters">Jan Grutters</name><affiliation><nlm:aff id="af19">ILD Center of Excellence, St Antonius Hospital, Division Heart and Lungs, University Medical Centre Utrecht, Utrecht, The Netherlands</nlm:aff></affiliation></author><author><name sortKey="Inoue, Yoshikazu" sort="Inoue, Yoshikazu" uniqKey="Inoue Y" first="Yoshikazu" last="Inoue">Yoshikazu Inoue</name><affiliation><nlm:aff id="af20">Clinical Research Center, National Hospital Organization Kinki-Chuo Chest Medical Center, Osaka, Japan</nlm:aff></affiliation></author><author><name sortKey="Kokosi, Maria" sort="Kokosi, Maria" uniqKey="Kokosi M" first="Maria" last="Kokosi">Maria Kokosi</name><affiliation><nlm:aff id="af21">Dept of Respiratory Medicine, Interstitial Lung Disease Unit, Royal Brompton Hospital, London, UK</nlm:aff></affiliation></author><author><name sortKey="Kondoh, Yasuhiro" sort="Kondoh, Yasuhiro" uniqKey="Kondoh Y" first="Yasuhiro" last="Kondoh">Yasuhiro Kondoh</name><affiliation><nlm:aff id="af22">Tosei General Hospital, Dept of Respiratory Medicine and Allergy, Seto, Japan</nlm:aff></affiliation></author><author><name sortKey="Kouranos, Vasileios" sort="Kouranos, Vasileios" uniqKey="Kouranos V" first="Vasileios" last="Kouranos">Vasileios Kouranos</name><affiliation><nlm:aff id="af21">Dept of Respiratory Medicine, Interstitial Lung Disease Unit, Royal Brompton Hospital, London, UK</nlm:aff></affiliation></author><author><name sortKey="Kreuter, Michael" sort="Kreuter, Michael" uniqKey="Kreuter M" first="Michael" last="Kreuter">Michael Kreuter</name><affiliation><nlm:aff id="af23">Center for interstitial and rare lung diseases, Pneumology and respiratory critical care medicine, Thoraxklinik, University of Heidelberg, and Translational Lung Research Center Heidelberg, Member of the German Center for Lung Research (DZL), Heidelberg, Germany</nlm:aff></affiliation></author><author><name sortKey="Johannson, Kerri" sort="Johannson, Kerri" uniqKey="Johannson K" first="Kerri" last="Johannson">Kerri Johannson</name><affiliation><nlm:aff id="af24">University Of Calgary, Calgary, AB, Canada</nlm:aff></affiliation></author><author><name sortKey="Judge, Eoin" sort="Judge, Eoin" uniqKey="Judge E" first="Eoin" last="Judge">Eoin Judge</name><affiliation><nlm:aff id="af25">Respiratory Medicine and National Lung Transplantation Unit, Mater Misericordiae University Hospital, Dublin , Ireland</nlm:aff></affiliation></author><author><name sortKey="Ley, Brett" sort="Ley, Brett" uniqKey="Ley B" first="Brett" last="Ley">Brett Ley</name><affiliation><nlm:aff id="af26">Medicine, University of California San Francisco, San Francisco, CA, USA</nlm:aff></affiliation></author><author><name sortKey="Margaritopoulos, George" sort="Margaritopoulos, George" uniqKey="Margaritopoulos G" first="George" last="Margaritopoulos">George Margaritopoulos</name><affiliation><nlm:aff id="af21">Dept of Respiratory Medicine, Interstitial Lung Disease Unit, Royal Brompton Hospital, London, UK</nlm:aff></affiliation></author><author><name sortKey="Martinez, Fernando J" sort="Martinez, Fernando J" uniqKey="Martinez F" first="Fernando J." last="Martinez">Fernando J. Martinez</name><affiliation><nlm:aff id="af27">Weill Cornell Medicine, New York, NY, USA</nlm:aff></affiliation></author><author><name sortKey="Molina Molina, Maria" sort="Molina Molina, Maria" uniqKey="Molina Molina M" first="Maria" last="Molina-Molina">Maria Molina-Molina</name><affiliation><nlm:aff id="af28">University Hospital of Bellvitge-IDIBELL-CIBERES, Barcelona, Spain</nlm:aff></affiliation></author><author><name sortKey="Morais, Ant Nio" sort="Morais, Ant Nio" uniqKey="Morais A" first="Ant Nio" last="Morais">Ant Nio Morais</name><affiliation><nlm:aff id="af29">Centro Hospitalar São João – Pulmonology, Faculdade de Medicina do Porto, Alameda Professor Hernâni Monteiro, Oporto, Portugal</nlm:aff></affiliation></author><author><name sortKey="Nunes, Hilario" sort="Nunes, Hilario" uniqKey="Nunes H" first="Hilario" last="Nunes">Hilario Nunes</name><affiliation><nlm:aff id="af30">Paris 13 University, Sorbonne Paris Cité, Service de Pneumologie, Hopital Avicenne, Bobigny, France</nlm:aff></affiliation></author><author><name sortKey="Raghu, Ganesh" sort="Raghu, Ganesh" uniqKey="Raghu G" first="Ganesh" last="Raghu">Ganesh Raghu</name><affiliation><nlm:aff id="af31">University of Washington - Center for Interstitial Lung Disease, Seattle, WA, USA</nlm:aff></affiliation></author><author><name sortKey="Ryerson, Christopher J" sort="Ryerson, Christopher J" uniqKey="Ryerson C" first="Christopher J." last="Ryerson">Christopher J. Ryerson</name><affiliation><nlm:aff id="af32">University of British Columbia – Medicine, Vancouver, BC, Canada</nlm:aff></affiliation></author><author><name sortKey="Selman, Moises" sort="Selman, Moises" uniqKey="Selman M" first="Moises" last="Selman">Moises Selman</name><affiliation><nlm:aff id="af33">Instituto Nacional de Enfermedades Respiratorias “Ismael Cosio Villegas”, Mexico City, Mexico</nlm:aff></affiliation></author><author><name sortKey="Spagnolo, Paolo" sort="Spagnolo, Paolo" uniqKey="Spagnolo P" first="Paolo" last="Spagnolo">Paolo Spagnolo</name><affiliation><nlm:aff id="af34">Section of Respiratory Diseases, Dept of Cardiac, Thoracic and Vascular Sciences, University of Padova, Padova, Italy</nlm:aff></affiliation></author><author><name sortKey="Taniguchi, Hiroyuki" sort="Taniguchi, Hiroyuki" uniqKey="Taniguchi H" first="Hiroyuki" last="Taniguchi">Hiroyuki Taniguchi</name><affiliation><nlm:aff id="af22">Tosei General Hospital, Dept of Respiratory Medicine and Allergy, Seto, Japan</nlm:aff></affiliation></author><author><name sortKey="Tomassetti, Sara" sort="Tomassetti, Sara" uniqKey="Tomassetti S" first="Sara" last="Tomassetti">Sara Tomassetti</name><affiliation><nlm:aff id="af4">Department of Diseases of the Thorax, Ospedale GB Morgagni, Forlì, Italy</nlm:aff></affiliation></author><author><name sortKey="Valeyre, Dominique" sort="Valeyre, Dominique" uniqKey="Valeyre D" first="Dominique" last="Valeyre">Dominique Valeyre</name><affiliation><nlm:aff id="af30">Paris 13 University, Sorbonne Paris Cité, Service de Pneumologie, Hopital Avicenne, Bobigny, France</nlm:aff></affiliation></author><author><name sortKey="Wijsenbeek, Marlies" sort="Wijsenbeek, Marlies" uniqKey="Wijsenbeek M" first="Marlies" last="Wijsenbeek">Marlies Wijsenbeek</name><affiliation><nlm:aff id="af35">Dept of Pulmonary Diseases, Erasmus MC, University Hospital Rotterdam, Rotterdam, The Netherlands</nlm:aff></affiliation></author><author><name sortKey="Wuyts, Wim" sort="Wuyts, Wim" uniqKey="Wuyts W" first="Wim" last="Wuyts">Wim Wuyts</name><affiliation><nlm:aff id="af36">Respiratory Medicine, University Hospitals Leuven, Leuven, Belgium</nlm:aff></affiliation></author><author><name sortKey="Hansell, David" sort="Hansell, David" uniqKey="Hansell D" first="David" last="Hansell">David Hansell</name><affiliation><nlm:aff id="af37">Dept of Thoracic Imaging, Royal Brompton Hospital, London, UK</nlm:aff></affiliation></author><author><name sortKey="Wells, Athol" sort="Wells, Athol" uniqKey="Wells A" first="Athol" last="Wells">Athol Wells</name><affiliation><nlm:aff id="af38">Interstitial Lung Disease Unit, Royal Brompton Hospital, London, UK</nlm:aff></affiliation></author></titleStmt><publicationStmt><idno type="wicri:source">PMC</idno><idno type="pmid">28860269</idno><idno type="pmc">5593374</idno><idno type="url">http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5593374</idno><idno type="RBID">PMC:5593374</idno><idno type="doi">10.1183/13993003.00936-2017</idno><date when="2017">2017</date><idno type="wicri:Area/Pmc/Corpus">002472</idno><idno type="wicri:explorRef" wicri:stream="Pmc" wicri:step="Corpus" wicri:corpus="PMC">002472</idno></publicationStmt><sourceDesc><biblStruct><analytic><title xml:lang="en" level="a" type="main">Diagnostic accuracy of a clinical diagnosis of idiopathic pulmonary fibrosis: an international case–cohort study</title><author><name sortKey="Walsh, Simon L F" sort="Walsh, Simon L F" uniqKey="Walsh S" first="Simon L. F." last="Walsh">Simon L. F. Walsh</name><affiliation><nlm:aff id="af1">Dept of Radiology, King's College Hospital Foundation Trust, London, UK</nlm:aff></affiliation></author><author><name sortKey="Maher, Toby M" sort="Maher, Toby M" uniqKey="Maher T" first="Toby M." last="Maher">Toby M. Maher</name><affiliation><nlm:aff id="af2">Dept of Respiratory Medicine, Interstitial Lung Disease Unit, Royal Brompton Hospital and National Heart and Lung Institute, Imperial College, London, UK</nlm:aff></affiliation></author><author><name sortKey="Kolb, Martin" sort="Kolb, Martin" uniqKey="Kolb M" first="Martin" last="Kolb">Martin Kolb</name><affiliation><nlm:aff id="af3">Depts of Medicine and Pathology/Molecular Medicine, McMaster University, Firestone Institute for Respiratory Health, Hamilton, ON, Canada</nlm:aff></affiliation></author><author><name sortKey="Poletti, Venerino" sort="Poletti, Venerino" uniqKey="Poletti V" first="Venerino" last="Poletti">Venerino Poletti</name><affiliation><nlm:aff id="af4">Department of Diseases of the Thorax, Ospedale GB Morgagni, Forlì, Italy</nlm:aff></affiliation><affiliation><nlm:aff id="af5">Dept of Respiratory Diseases and Allergy, Aarhus University Hospital, Aarhus, Denmark</nlm:aff></affiliation></author><author><name sortKey="Nusser, Richard" sort="Nusser, Richard" uniqKey="Nusser R" first="Richard" last="Nusser">Richard Nusser</name><affiliation><nlm:aff id="af6">Dept of Respiratory Medicine, Summit Hospital, Oakland, CA, USA</nlm:aff></affiliation></author><author><name sortKey="Richeldi, Luca" sort="Richeldi, Luca" uniqKey="Richeldi L" first="Luca" last="Richeldi">Luca Richeldi</name><affiliation><nlm:aff id="af7">Unità Operativa Complessa di Pneumologia, Università Cattolica del Sacro Cuore, Fondazione Policlinico A. Gemelli, Rome, Italy</nlm:aff></affiliation></author><author><name sortKey="Vancheri, Carlo" sort="Vancheri, Carlo" uniqKey="Vancheri C" first="Carlo" last="Vancheri">Carlo Vancheri</name><affiliation><nlm:aff id="af8">Dept of Clinical and Experimental Medicine, University of Catania, University - Hospital “Policlinico - Vitt. Emanuele”, Catania, Italy</nlm:aff></affiliation></author><author><name sortKey="Wilsher, Margaret L" sort="Wilsher, Margaret L" uniqKey="Wilsher M" first="Margaret L." last="Wilsher">Margaret L. Wilsher</name><affiliation><nlm:aff id="af9">Auckland District Health Board and the University of Auckland, Auckland, New Zealand</nlm:aff></affiliation></author><author><name sortKey="Antoniou, Katerina M" sort="Antoniou, Katerina M" uniqKey="Antoniou K" first="Katerina M." last="Antoniou">Katerina M. Antoniou</name><affiliation><nlm:aff id="af10">Dept of Respiratory Medicine, Faculty of Medicine, University of Crete, Heraklion, Greece</nlm:aff></affiliation></author><author><name sortKey="Behr, Juergen" sort="Behr, Juergen" uniqKey="Behr J" first="Jüergen" last="Behr">Jüergen Behr</name><affiliation><nlm:aff id="af11">Dept of Medicine V, University of Munich and Asklepios Fachkliniken Gauting, Comprehensive Pneumology Center, member of the German Center for Lung Research, Munich, Germany</nlm:aff></affiliation></author><author><name sortKey="Bendstrup, Elisabeth" sort="Bendstrup, Elisabeth" uniqKey="Bendstrup E" first="Elisabeth" last="Bendstrup">Elisabeth Bendstrup</name><affiliation><nlm:aff id="af5">Dept of Respiratory Diseases and Allergy, Aarhus University Hospital, Aarhus, Denmark</nlm:aff></affiliation></author><author><name sortKey="Brown, Kevin" sort="Brown, Kevin" uniqKey="Brown K" first="Kevin" last="Brown">Kevin Brown</name><affiliation><nlm:aff id="af12">National Jewish Health, Denver, CO, USA</nlm:aff></affiliation></author><author><name sortKey="Calandriello, Lucio" sort="Calandriello, Lucio" uniqKey="Calandriello L" first="Lucio" last="Calandriello">Lucio Calandriello</name><affiliation><nlm:aff id="af13">Institute of Radiology, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario A. Gemelli, Rome, Italy</nlm:aff></affiliation></author><author><name sortKey="Corte, Tamera J" sort="Corte, Tamera J" uniqKey="Corte T" first="Tamera J." last="Corte">Tamera J. Corte</name><affiliation><nlm:aff id="af14">Dept of Respiratory Medicine, Royal Prince Alfred Hospital, and University of Sydney, Sydney, Australia</nlm:aff></affiliation></author><author><name sortKey="Cottin, Vincent" sort="Cottin, Vincent" uniqKey="Cottin V" first="Vincent" last="Cottin">Vincent Cottin</name><affiliation><nlm:aff id="af15">Service de Pneumologie, Hopital L. Pradel, Lyon, France</nlm:aff></affiliation></author><author><name sortKey="Crestani, Bruno" sort="Crestani, Bruno" uniqKey="Crestani B" first="Bruno" last="Crestani">Bruno Crestani</name><affiliation><nlm:aff id="af16">APHP, Hopital Bichat, Service de Pneumologie A, Université Paris Diderot, Paris, France</nlm:aff></affiliation></author><author><name sortKey="Flaherty, Kevin" sort="Flaherty, Kevin" uniqKey="Flaherty K" first="Kevin" last="Flaherty">Kevin Flaherty</name><affiliation><nlm:aff id="af17">University of Michigan, Division of Pulmonary and Critical Care Medicine, Ann Arbor, MI, USA</nlm:aff></affiliation></author><author><name sortKey="Glaspole, Ian" sort="Glaspole, Ian" uniqKey="Glaspole I" first="Ian" last="Glaspole">Ian Glaspole</name><affiliation><nlm:aff id="af18">Alfred Health - Allergy, Immunology and Respiratory Medicine, Melbourne, Australia</nlm:aff></affiliation></author><author><name sortKey="Grutters, Jan" sort="Grutters, Jan" uniqKey="Grutters J" first="Jan" last="Grutters">Jan Grutters</name><affiliation><nlm:aff id="af19">ILD Center of Excellence, St Antonius Hospital, Division Heart and Lungs, University Medical Centre Utrecht, Utrecht, The Netherlands</nlm:aff></affiliation></author><author><name sortKey="Inoue, Yoshikazu" sort="Inoue, Yoshikazu" uniqKey="Inoue Y" first="Yoshikazu" last="Inoue">Yoshikazu Inoue</name><affiliation><nlm:aff id="af20">Clinical Research Center, National Hospital Organization Kinki-Chuo Chest Medical Center, Osaka, Japan</nlm:aff></affiliation></author><author><name sortKey="Kokosi, Maria" sort="Kokosi, Maria" uniqKey="Kokosi M" first="Maria" last="Kokosi">Maria Kokosi</name><affiliation><nlm:aff id="af21">Dept of Respiratory Medicine, Interstitial Lung Disease Unit, Royal Brompton Hospital, London, UK</nlm:aff></affiliation></author><author><name sortKey="Kondoh, Yasuhiro" sort="Kondoh, Yasuhiro" uniqKey="Kondoh Y" first="Yasuhiro" last="Kondoh">Yasuhiro Kondoh</name><affiliation><nlm:aff id="af22">Tosei General Hospital, Dept of Respiratory Medicine and Allergy, Seto, Japan</nlm:aff></affiliation></author><author><name sortKey="Kouranos, Vasileios" sort="Kouranos, Vasileios" uniqKey="Kouranos V" first="Vasileios" last="Kouranos">Vasileios Kouranos</name><affiliation><nlm:aff id="af21">Dept of Respiratory Medicine, Interstitial Lung Disease Unit, Royal Brompton Hospital, London, UK</nlm:aff></affiliation></author><author><name sortKey="Kreuter, Michael" sort="Kreuter, Michael" uniqKey="Kreuter M" first="Michael" last="Kreuter">Michael Kreuter</name><affiliation><nlm:aff id="af23">Center for interstitial and rare lung diseases, Pneumology and respiratory critical care medicine, Thoraxklinik, University of Heidelberg, and Translational Lung Research Center Heidelberg, Member of the German Center for Lung Research (DZL), Heidelberg, Germany</nlm:aff></affiliation></author><author><name sortKey="Johannson, Kerri" sort="Johannson, Kerri" uniqKey="Johannson K" first="Kerri" last="Johannson">Kerri Johannson</name><affiliation><nlm:aff id="af24">University Of Calgary, Calgary, AB, Canada</nlm:aff></affiliation></author><author><name sortKey="Judge, Eoin" sort="Judge, Eoin" uniqKey="Judge E" first="Eoin" last="Judge">Eoin Judge</name><affiliation><nlm:aff id="af25">Respiratory Medicine and National Lung Transplantation Unit, Mater Misericordiae University Hospital, Dublin , Ireland</nlm:aff></affiliation></author><author><name sortKey="Ley, Brett" sort="Ley, Brett" uniqKey="Ley B" first="Brett" last="Ley">Brett Ley</name><affiliation><nlm:aff id="af26">Medicine, University of California San Francisco, San Francisco, CA, USA</nlm:aff></affiliation></author><author><name sortKey="Margaritopoulos, George" sort="Margaritopoulos, George" uniqKey="Margaritopoulos G" first="George" last="Margaritopoulos">George Margaritopoulos</name><affiliation><nlm:aff id="af21">Dept of Respiratory Medicine, Interstitial Lung Disease Unit, Royal Brompton Hospital, London, UK</nlm:aff></affiliation></author><author><name sortKey="Martinez, Fernando J" sort="Martinez, Fernando J" uniqKey="Martinez F" first="Fernando J." last="Martinez">Fernando J. Martinez</name><affiliation><nlm:aff id="af27">Weill Cornell Medicine, New York, NY, USA</nlm:aff></affiliation></author><author><name sortKey="Molina Molina, Maria" sort="Molina Molina, Maria" uniqKey="Molina Molina M" first="Maria" last="Molina-Molina">Maria Molina-Molina</name><affiliation><nlm:aff id="af28">University Hospital of Bellvitge-IDIBELL-CIBERES, Barcelona, Spain</nlm:aff></affiliation></author><author><name sortKey="Morais, Ant Nio" sort="Morais, Ant Nio" uniqKey="Morais A" first="Ant Nio" last="Morais">Ant Nio Morais</name><affiliation><nlm:aff id="af29">Centro Hospitalar São João – Pulmonology, Faculdade de Medicina do Porto, Alameda Professor Hernâni Monteiro, Oporto, Portugal</nlm:aff></affiliation></author><author><name sortKey="Nunes, Hilario" sort="Nunes, Hilario" uniqKey="Nunes H" first="Hilario" last="Nunes">Hilario Nunes</name><affiliation><nlm:aff id="af30">Paris 13 University, Sorbonne Paris Cité, Service de Pneumologie, Hopital Avicenne, Bobigny, France</nlm:aff></affiliation></author><author><name sortKey="Raghu, Ganesh" sort="Raghu, Ganesh" uniqKey="Raghu G" first="Ganesh" last="Raghu">Ganesh Raghu</name><affiliation><nlm:aff id="af31">University of Washington - Center for Interstitial Lung Disease, Seattle, WA, USA</nlm:aff></affiliation></author><author><name sortKey="Ryerson, Christopher J" sort="Ryerson, Christopher J" uniqKey="Ryerson C" first="Christopher J." last="Ryerson">Christopher J. Ryerson</name><affiliation><nlm:aff id="af32">University of British Columbia – Medicine, Vancouver, BC, Canada</nlm:aff></affiliation></author><author><name sortKey="Selman, Moises" sort="Selman, Moises" uniqKey="Selman M" first="Moises" last="Selman">Moises Selman</name><affiliation><nlm:aff id="af33">Instituto Nacional de Enfermedades Respiratorias “Ismael Cosio Villegas”, Mexico City, Mexico</nlm:aff></affiliation></author><author><name sortKey="Spagnolo, Paolo" sort="Spagnolo, Paolo" uniqKey="Spagnolo P" first="Paolo" last="Spagnolo">Paolo Spagnolo</name><affiliation><nlm:aff id="af34">Section of Respiratory Diseases, Dept of Cardiac, Thoracic and Vascular Sciences, University of Padova, Padova, Italy</nlm:aff></affiliation></author><author><name sortKey="Taniguchi, Hiroyuki" sort="Taniguchi, Hiroyuki" uniqKey="Taniguchi H" first="Hiroyuki" last="Taniguchi">Hiroyuki Taniguchi</name><affiliation><nlm:aff id="af22">Tosei General Hospital, Dept of Respiratory Medicine and Allergy, Seto, Japan</nlm:aff></affiliation></author><author><name sortKey="Tomassetti, Sara" sort="Tomassetti, Sara" uniqKey="Tomassetti S" first="Sara" last="Tomassetti">Sara Tomassetti</name><affiliation><nlm:aff id="af4">Department of Diseases of the Thorax, Ospedale GB Morgagni, Forlì, Italy</nlm:aff></affiliation></author><author><name sortKey="Valeyre, Dominique" sort="Valeyre, Dominique" uniqKey="Valeyre D" first="Dominique" last="Valeyre">Dominique Valeyre</name><affiliation><nlm:aff id="af30">Paris 13 University, Sorbonne Paris Cité, Service de Pneumologie, Hopital Avicenne, Bobigny, France</nlm:aff></affiliation></author><author><name sortKey="Wijsenbeek, Marlies" sort="Wijsenbeek, Marlies" uniqKey="Wijsenbeek M" first="Marlies" last="Wijsenbeek">Marlies Wijsenbeek</name><affiliation><nlm:aff id="af35">Dept of Pulmonary Diseases, Erasmus MC, University Hospital Rotterdam, Rotterdam, The Netherlands</nlm:aff></affiliation></author><author><name sortKey="Wuyts, Wim" sort="Wuyts, Wim" uniqKey="Wuyts W" first="Wim" last="Wuyts">Wim Wuyts</name><affiliation><nlm:aff id="af36">Respiratory Medicine, University Hospitals Leuven, Leuven, Belgium</nlm:aff></affiliation></author><author><name sortKey="Hansell, David" sort="Hansell, David" uniqKey="Hansell D" first="David" last="Hansell">David Hansell</name><affiliation><nlm:aff id="af37">Dept of Thoracic Imaging, Royal Brompton Hospital, London, UK</nlm:aff></affiliation></author><author><name sortKey="Wells, Athol" sort="Wells, Athol" uniqKey="Wells A" first="Athol" last="Wells">Athol Wells</name><affiliation><nlm:aff id="af38">Interstitial Lung Disease Unit, Royal Brompton Hospital, London, UK</nlm:aff></affiliation></author></analytic><series><title level="j">The European Respiratory Journal</title><idno type="ISSN">0903-1936</idno><idno type="eISSN">1399-3003</idno><imprint><date when="2017">2017</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass></textClass></profileDesc></teiHeader><front><div type="abstract" xml:lang="en"><p>We conducted an international study of idiopathic pulmonary fibrosis (IPF) diagnosis among a large group of physicians and compared their diagnostic performance to a panel of IPF experts.</p><p>A total of 1141 respiratory physicians and 34 IPF experts participated. Participants evaluated 60 cases of interstitial lung disease (ILD) without interdisciplinary consultation. Diagnostic agreement was measured using the weighted kappa coefficient (κ<sub>w</sub>). Prognostic discrimination between IPF and other ILDs was used to validate diagnostic accuracy for first-choice diagnoses of IPF and were compared using the C-index.</p><p>A total of 404 physicians completed the study. Agreement for IPF diagnosis was higher among expert physicians (κ<sub>w</sub>=0.65, IQR 0.53–0.72, p<0.0001) than academic physicians (κ<sub>w</sub>=0.56, IQR 0.45–0.65, p<0.0001) or physicians with access to multidisciplinary team (MDT) meetings (κ<sub>w</sub>=0.54, IQR 0.45–0.64, p<0.0001). The prognostic accuracy of academic physicians with >20 years of experience (C-index=0.72, IQR 0.0–0.73, p=0.229) and non-university hospital physicians with more than 20 years of experience, attending weekly MDT meetings (C-index=0.72, IQR 0.70–0.72, p=0.052), did not differ significantly (p=0.229 and p=0.052 respectively) from the expert panel (C-index=0.74 IQR 0.72–0.75).</p><p>Experienced respiratory physicians at university-based institutions diagnose IPF with similar prognostic accuracy to IPF experts. 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<front><journal-meta><journal-id journal-id-type="nlm-ta">Eur Respir J</journal-id><journal-id journal-id-type="iso-abbrev">Eur. Respir. J</journal-id><journal-id journal-id-type="publisher-id">ERJ</journal-id><journal-id journal-id-type="hwp">erj</journal-id><journal-title-group><journal-title>The European Respiratory Journal</journal-title></journal-title-group><issn pub-type="ppub">0903-1936</issn><issn pub-type="epub">1399-3003</issn><publisher><publisher-name>European Respiratory Society</publisher-name></publisher></journal-meta><article-meta><article-id pub-id-type="pmid">28860269</article-id><article-id pub-id-type="pmc">5593374</article-id><article-id pub-id-type="doi">10.1183/13993003.00936-2017</article-id><article-id pub-id-type="publisher-id">ERJ-00936-2017</article-id><article-categories><subj-group subj-group-type="heading"><subject>Original Articles</subject><subj-group><subject>Interstitial Lung Diseases</subject></subj-group></subj-group><subj-group subj-group-type="hwp-journal-coll"><subject>13</subject></subj-group></article-categories><title-group><article-title>Diagnostic accuracy of a clinical diagnosis of idiopathic pulmonary fibrosis: an international case–cohort study</article-title><alt-title alt-title-type="short">Diagnostic accuracy of a clinical diagnosis of IPF</alt-title></title-group><contrib-group><contrib contrib-type="author" corresp="yes"><name><surname>Walsh</surname><given-names>Simon L.F.</given-names></name><xref ref-type="aff" rid="af1">1</xref><xref ref-type="corresp" rid="cor1"></xref></contrib><contrib contrib-type="author"><name><surname>Maher</surname><given-names>Toby M.</given-names></name><xref ref-type="aff" rid="af2">2</xref></contrib><contrib contrib-type="author"><name><surname>Kolb</surname><given-names>Martin</given-names></name><xref ref-type="aff" rid="af3">3</xref></contrib><contrib contrib-type="author"><name><surname>Poletti</surname><given-names>Venerino</given-names></name><xref ref-type="aff" rid="af4">4</xref><xref ref-type="aff" rid="af5">5</xref></contrib><contrib contrib-type="author"><name><surname>Nusser</surname><given-names>Richard</given-names></name><xref ref-type="aff" rid="af6">6</xref></contrib><contrib contrib-type="author"><name><surname>Richeldi</surname><given-names>Luca</given-names></name><xref ref-type="aff" rid="af7">7</xref></contrib><contrib contrib-type="author"><name><surname>Vancheri</surname><given-names>Carlo</given-names></name><xref ref-type="aff" rid="af8">8</xref></contrib><contrib contrib-type="author"><name><surname>Wilsher</surname><given-names>Margaret L.</given-names></name><xref ref-type="aff" rid="af9">9</xref></contrib><contrib contrib-type="author"><name><surname>Antoniou</surname><given-names>Katerina M.</given-names></name><xref ref-type="aff" rid="af10">10</xref></contrib><contrib contrib-type="author"><name><surname>Behr</surname><given-names>Jüergen</given-names></name><xref ref-type="aff" rid="af11">11</xref></contrib><contrib contrib-type="author"><name><surname>Bendstrup</surname><given-names>Elisabeth</given-names></name><xref ref-type="aff" rid="af5">5</xref></contrib><contrib contrib-type="author"><name><surname>Brown</surname><given-names>Kevin</given-names></name><xref ref-type="aff" rid="af12">12</xref></contrib><contrib contrib-type="author"><name><surname>Calandriello</surname><given-names>Lucio</given-names></name><xref ref-type="aff" rid="af13">13</xref></contrib><contrib contrib-type="author"><name><surname>Corte</surname><given-names>Tamera J.</given-names></name><xref ref-type="aff" rid="af14">14</xref></contrib><contrib contrib-type="author"><contrib-id contrib-id-type="orcid" authenticated="false">http://orcid.org/0000-0002-5591-0955</contrib-id><name><surname>Cottin</surname><given-names>Vincent</given-names></name><xref ref-type="aff" rid="af15">15</xref></contrib><contrib contrib-type="author"><name><surname>Crestani</surname><given-names>Bruno</given-names></name><xref ref-type="aff" rid="af16">16</xref></contrib><contrib contrib-type="author"><name><surname>Flaherty</surname><given-names>Kevin</given-names></name><xref ref-type="aff" rid="af17">17</xref></contrib><contrib contrib-type="author"><name><surname>Glaspole</surname><given-names>Ian</given-names></name><xref ref-type="aff" rid="af18">18</xref></contrib><contrib contrib-type="author"><name><surname>Grutters</surname><given-names>Jan</given-names></name><xref ref-type="aff" rid="af19">19</xref></contrib><contrib contrib-type="author"><name><surname>Inoue</surname><given-names>Yoshikazu</given-names></name><xref ref-type="aff" rid="af20">20</xref></contrib><contrib contrib-type="author"><name><surname>Kokosi</surname><given-names>Maria</given-names></name><xref ref-type="aff" rid="af21">21</xref></contrib><contrib contrib-type="author"><name><surname>Kondoh</surname><given-names>Yasuhiro</given-names></name><xref ref-type="aff" rid="af22">22</xref></contrib><contrib contrib-type="author"><name><surname>Kouranos</surname><given-names>Vasileios</given-names></name><xref ref-type="aff" rid="af21">21</xref></contrib><contrib contrib-type="author"><name><surname>Kreuter</surname><given-names>Michael</given-names></name><xref ref-type="aff" rid="af23">23</xref></contrib><contrib contrib-type="author"><name><surname>Johannson</surname><given-names>Kerri</given-names></name><xref ref-type="aff" rid="af24">24</xref></contrib><contrib contrib-type="author"><name><surname>Judge</surname><given-names>Eoin</given-names></name><xref ref-type="aff" rid="af25">25</xref></contrib><contrib contrib-type="author"><name><surname>Ley</surname><given-names>Brett</given-names></name><xref ref-type="aff" rid="af26">26</xref></contrib><contrib contrib-type="author"><name><surname>Margaritopoulos</surname><given-names>George</given-names></name><xref ref-type="aff" rid="af21">21</xref></contrib><contrib contrib-type="author"><name><surname>Martinez</surname><given-names>Fernando J.</given-names></name><xref ref-type="aff" rid="af27">27</xref></contrib><contrib contrib-type="author"><name><surname>Molina-Molina</surname><given-names>Maria</given-names></name><xref ref-type="aff" rid="af28">28</xref></contrib><contrib contrib-type="author"><name><surname>Morais</surname><given-names>António</given-names></name><xref ref-type="aff" rid="af29">29</xref></contrib><contrib contrib-type="author"><name><surname>Nunes</surname><given-names>Hilario</given-names></name><xref ref-type="aff" rid="af30">30</xref></contrib><contrib contrib-type="author"><name><surname>Raghu</surname><given-names>Ganesh</given-names></name><xref ref-type="aff" rid="af31">31</xref></contrib><contrib contrib-type="author"><name><surname>Ryerson</surname><given-names>Christopher J.</given-names></name><xref ref-type="aff" rid="af32">32</xref></contrib><contrib contrib-type="author"><name><surname>Selman</surname><given-names>Moises</given-names></name><xref ref-type="aff" rid="af33">33</xref></contrib><contrib contrib-type="author"><name><surname>Spagnolo</surname><given-names>Paolo</given-names></name><xref ref-type="aff" rid="af34">34</xref></contrib><contrib contrib-type="author"><name><surname>Taniguchi</surname><given-names>Hiroyuki</given-names></name><xref ref-type="aff" rid="af22">22</xref></contrib><contrib contrib-type="author"><name><surname>Tomassetti</surname><given-names>Sara</given-names></name><xref ref-type="aff" rid="af4">4</xref></contrib><contrib contrib-type="author"><name><surname>Valeyre</surname><given-names>Dominique</given-names></name><xref ref-type="aff" rid="af30">30</xref></contrib><contrib contrib-type="author"><name><surname>Wijsenbeek</surname><given-names>Marlies</given-names></name><xref ref-type="aff" rid="af35">35</xref></contrib><contrib contrib-type="author"><name><surname>Wuyts</surname><given-names>Wim</given-names></name><xref ref-type="aff" rid="af36">36</xref></contrib><contrib contrib-type="author"><name><surname>Hansell</surname><given-names>David</given-names></name><xref ref-type="aff" rid="af37">37</xref></contrib><contrib contrib-type="author"><name><surname>Wells</surname><given-names>Athol</given-names></name><xref ref-type="aff" rid="af38">38</xref></contrib><on-behalf-of>on behalf of The IPF Project Consortium</on-behalf-of><xref ref-type="aff" rid="af39">39</xref></contrib-group><aff id="af1"><label>1</label>Dept of Radiology, King's College Hospital Foundation Trust, London, UK</aff><aff id="af2"><label>2</label>Dept of Respiratory Medicine, Interstitial Lung Disease Unit, Royal Brompton Hospital and National Heart and Lung Institute, Imperial College, London, UK</aff><aff id="af3"><label>3</label>Depts of Medicine and Pathology/Molecular Medicine, McMaster University, Firestone Institute for Respiratory Health, Hamilton, ON, Canada</aff><aff id="af4"><label>4</label>Department of Diseases of the Thorax, Ospedale GB Morgagni, Forlì, Italy</aff><aff id="af5"><label>5</label>Dept of Respiratory Diseases and Allergy, Aarhus University Hospital, Aarhus, Denmark</aff><aff id="af6"><label>6</label>Dept of Respiratory Medicine, Summit Hospital, Oakland, CA, USA</aff><aff id="af7"><label>7</label>Unità Operativa Complessa di Pneumologia, Università Cattolica del Sacro Cuore, Fondazione Policlinico A. Gemelli, Rome, Italy</aff><aff id="af8"><label>8</label>Dept of Clinical and Experimental Medicine, University of Catania, University - Hospital “Policlinico - Vitt. Emanuele”, Catania, Italy</aff><aff id="af9"><label>9</label>Auckland District Health Board and the University of Auckland, Auckland, New Zealand</aff><aff id="af10"><label>10</label>Dept of Respiratory Medicine, Faculty of Medicine, University of Crete, Heraklion, Greece</aff><aff id="af11"><label>11</label>Dept of Medicine V, University of Munich and Asklepios Fachkliniken Gauting, Comprehensive Pneumology Center, member of the German Center for Lung Research, Munich, Germany</aff><aff id="af12"><label>12</label>National Jewish Health, Denver, CO, USA</aff><aff id="af13"><label>13</label>Institute of Radiology, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario A. Gemelli, Rome, Italy</aff><aff id="af14"><label>14</label>Dept of Respiratory Medicine, Royal Prince Alfred Hospital, and University of Sydney, Sydney, Australia</aff><aff id="af15"><label>15</label>Service de Pneumologie, Hopital L. Pradel, Lyon, France</aff><aff id="af16"><label>16</label>APHP, Hopital Bichat, Service de Pneumologie A, Université Paris Diderot, Paris, France</aff><aff id="af17"><label>17</label>University of Michigan, Division of Pulmonary and Critical Care Medicine, Ann Arbor, MI, USA</aff><aff id="af18"><label>18</label>Alfred Health - Allergy, Immunology and Respiratory Medicine, Melbourne, Australia</aff><aff id="af19"><label>19</label>ILD Center of Excellence, St Antonius Hospital, Division Heart and Lungs, University Medical Centre Utrecht, Utrecht, The Netherlands</aff><aff id="af20"><label>20</label>Clinical Research Center, National Hospital Organization Kinki-Chuo Chest Medical Center, Osaka, Japan</aff><aff id="af21"><label>21</label>Dept of Respiratory Medicine, Interstitial Lung Disease Unit, Royal Brompton Hospital, London, UK</aff><aff id="af22"><label>22</label>Tosei General Hospital, Dept of Respiratory Medicine and Allergy, Seto, Japan</aff><aff id="af23"><label>23</label>Center for interstitial and rare lung diseases, Pneumology and respiratory critical care medicine, Thoraxklinik, University of Heidelberg, and Translational Lung Research Center Heidelberg, Member of the German Center for Lung Research (DZL), Heidelberg, Germany</aff><aff id="af24"><label>24</label>University Of Calgary, Calgary, AB, Canada</aff><aff id="af25"><label>25</label>Respiratory Medicine and National Lung Transplantation Unit, Mater Misericordiae University Hospital, Dublin , Ireland</aff><aff id="af26"><label>26</label>Medicine, University of California San Francisco, San Francisco, CA, USA</aff><aff id="af27"><label>27</label>Weill Cornell Medicine, New York, NY, USA</aff><aff id="af28"><label>28</label>University Hospital of Bellvitge-IDIBELL-CIBERES, Barcelona, Spain</aff><aff id="af29"><label>29</label>Centro Hospitalar São João – Pulmonology, Faculdade de Medicina do Porto, Alameda Professor Hernâni Monteiro, Oporto, Portugal</aff><aff id="af30"><label>30</label>Paris 13 University, Sorbonne Paris Cité, Service de Pneumologie, Hopital Avicenne, Bobigny, France</aff><aff id="af31"><label>31</label>University of Washington - Center for Interstitial Lung Disease, Seattle, WA, USA</aff><aff id="af32"><label>32</label>University of British Columbia – Medicine, Vancouver, BC, Canada</aff><aff id="af33"><label>33</label>Instituto Nacional de Enfermedades Respiratorias “Ismael Cosio Villegas”, Mexico City, Mexico</aff><aff id="af34"><label>34</label>Section of Respiratory Diseases, Dept of Cardiac, Thoracic and Vascular Sciences, University of Padova, Padova, Italy</aff><aff id="af35"><label>35</label>Dept of Pulmonary Diseases, Erasmus MC, University Hospital Rotterdam, Rotterdam, The Netherlands</aff><aff id="af36"><label>36</label>Respiratory Medicine, University Hospitals Leuven, Leuven, Belgium</aff><aff id="af37"><label>37</label>Dept of Thoracic Imaging, Royal Brompton Hospital, London, UK</aff><aff id="af38"><label>38</label>Interstitial Lung Disease Unit, Royal Brompton Hospital, London, UK</aff><aff id="af39"><label>39</label>A full list of members of the IPF Project Consortium can be found in the acknowledgements section</aff><author-notes><corresp id="cor1">Simon L.F. Walsh, Kings College Hospital Foundation Trust, Denmark Hill, London SE5 9RS, UK. E-mail: <email>slfwalsh@gmail.com</email></corresp></author-notes><pub-date pub-type="collection"><month>8</month><year>2017</year></pub-date><pub-date pub-type="epub"><day>31</day><month>8</month><year>2017</year></pub-date><volume>50</volume><issue>2</issue><elocation-id>1700936</elocation-id><history><date date-type="received"><day>07</day><month>5</month><year>2017</year></date><date date-type="accepted"><day>30</day><month>5</month><year>2017</year></date></history><permissions><copyright-statement>Copyright ©ERS 2017</copyright-statement><copyright-year>2017</copyright-year></permissions><abstract><p>We conducted an international study of idiopathic pulmonary fibrosis (IPF) diagnosis among a large group of physicians and compared their diagnostic performance to a panel of IPF experts.</p><p>A total of 1141 respiratory physicians and 34 IPF experts participated. Participants evaluated 60 cases of interstitial lung disease (ILD) without interdisciplinary consultation. Diagnostic agreement was measured using the weighted kappa coefficient (κ<sub>w</sub>). Prognostic discrimination between IPF and other ILDs was used to validate diagnostic accuracy for first-choice diagnoses of IPF and were compared using the C-index.</p><p>A total of 404 physicians completed the study. Agreement for IPF diagnosis was higher among expert physicians (κ<sub>w</sub>=0.65, IQR 0.53–0.72, p<0.0001) than academic physicians (κ<sub>w</sub>=0.56, IQR 0.45–0.65, p<0.0001) or physicians with access to multidisciplinary team (MDT) meetings (κ<sub>w</sub>=0.54, IQR 0.45–0.64, p<0.0001). The prognostic accuracy of academic physicians with >20 years of experience (C-index=0.72, IQR 0.0–0.73, p=0.229) and non-university hospital physicians with more than 20 years of experience, attending weekly MDT meetings (C-index=0.72, IQR 0.70–0.72, p=0.052), did not differ significantly (p=0.229 and p=0.052 respectively) from the expert panel (C-index=0.74 IQR 0.72–0.75).</p><p>Experienced respiratory physicians at university-based institutions diagnose IPF with similar prognostic accuracy to IPF experts. Regular MDT meeting attendance improves the prognostic accuracy of experienced non-university practitioners to levels achieved by IPF experts.</p></abstract><abstract abstract-type="short"><p><bold>Academic status, access to MDT meetings and clinician experience predict accuracy of a clinical diagnosis of IPF</bold><ext-link ext-link-type="uri" xlink:href="http://ow.ly/k43W30cTMg1">http://ow.ly/k43W30cTMg1</ext-link></p></abstract></article-meta></front><body><sec sec-type="intro" id="s1"><title>Introduction</title><p>Idiopathic pulmonary fibrosis (IPF) is characterised by progressive loss of lung function and a particularly poor prognosis [<xref rid="C1" ref-type="bibr">1</xref>]. Although it is often regarded as a rare disorder, in 2012 1% of all deaths in the UK occurred because of pulmonary fibrosis [<xref rid="C2" ref-type="bibr">2</xref>] and the incidence of IPF is expected to continue to rise [<xref rid="C3" ref-type="bibr">3</xref>–<xref rid="C8" ref-type="bibr">8</xref>]. Accurate IPF diagnosis has increased in importance with the advent of antifibrotic therapies and ongoing enrolment in IPF treatment trials [<xref rid="C9" ref-type="bibr">9</xref>, <xref rid="C10" ref-type="bibr">10</xref>].</p><p>Although the ATS/ERS/JRS/ALAT guideline diagnostic recommendations emphasise the importance of a multidisciplinary approach when diagnosing IPF [<xref rid="C11" ref-type="bibr">11</xref>–<xref rid="C13" ref-type="bibr">13</xref>], less experienced non-academic clinicians outside regional centres may not have access to multidisciplinary team (MDT) meetings [<xref rid="C14" ref-type="bibr">14</xref>]. Therefore, the diagnostic accuracy of clinicians acting in isolation is of practical importance. In the absence of a reference standard, one approach to evaluating the diagnostic skills of clinicians is to examine separations in mortality between patients diagnosed with IPF and those diagnosed with other ILDs, a method used in a recent study of multidisciplinary diagnosis [<xref rid="C15" ref-type="bibr">15</xref>]. The most accurate discrimination between IPF and non-IPF diagnoses should, in principle, provide the greatest separation in outcomes.</p><p>The aim of this study was to evaluate and compare IPF diagnoses made by non-academic clinicians, university-affiliated clinicians and an international panel of IPF experts, using three surrogates of diagnostic accuracy: diagnostic confidence, diagnostic agreement and prognostic accuracy (which was examined in non-expert subgroups against years of experience and access to an MDT meeting).</p></sec><sec sec-type="materials|methods" id="s2"><title>Materials and methods</title><sec id="s2a"><title>Case collection</title><p>The study protocol was approved by the NHS Health Research Authority, and for this retrospective examination of clinically indicated data, the need for patient consent was waived. We selected consecutive patients presenting to the interstitial lung disease (ILD) unit of the Royal Brompton and Harefield NHS Foundation Trust (London, UK) between January 5, 2010, and October 25, 2010 (supplementary figure A1). This approach allowed an analysis of 5-year survival and also meant that patients included in the study were selected from a pre-antifibrotic therapy era. Therefore, outcome distinctions between patients with IPF and those without this disease were not confounded by antifibrotic therapy. Since referral rates of patients with suspected IPF to the host institution in 2010 differed (25% of all referrals) from 2015 (36% of all referrals), we enriched the cohort with consecutive patients referred to the host institution between January 5, 2010, and October 25, 2010, and who were diagnosed with IPF by the host institution, to match 2015 IPF referral rates. Exclusion criteria were as follows.</p><p>1) An established diagnosis of connective tissue disease prior to presentation to the host institution. In these patients, the diagnosis of connective tissue disease-related ILD is usually straightforward and might spuriously increase overall diagnostic agreement [<xref rid="C15" ref-type="bibr">15</xref>].</p><p>2) Non-availability of imaging or lung function tests at presentation.</p><p>3) Diffusing capacity of the lung for carbon monoxide (<italic>D</italic><sub>LCO</sub>) <30% predicted, excluded because: a) clinicians might assume that the presence of end-stage fibrosis indicates IPF thus impacting diagnostic agreement and accuracy for an IPF diagnosis; b) although patients with end-stage fibrotic lung disease may occasionally be referred to the host institution, this may not reflect referral patterns to less specialised centres; and c) treatment may be less effective in patients with end-stage fibrosis reducing the importance of diagnostic precision.</p></sec><sec id="s2b"><title>Participating physicians</title><p>Between January 1, 2015, and July 1, 2016, we performed an Internet search, country by country, for practising respiratory physicians. Physician experience, nationality, academic status (working at a university hospital or not a university hospital) or subspecialist interests within respiratory medicine did not influence inclusion eligibility. This search included the European Respiratory Society Diffuse Parenchymal Lung Disease Assembly and the American Thoracic Society Clinical Problems Assembly. During July 2016 an invitation to participate in the study was extended to all of the physicians identified. In addition to this group, an expert panel was created, comprising respiratory physicians with specialist expertise in the diagnosis and management of ILD working in specialist ILD centres and with a track record of publications in this field. For the purposes of this study, physicians working at university-affiliated institutions are referred to as university physicians or academic physicians, and physicians not working at university-affiliated institutions are referred to as non-university physicians or non-academic physicians.</p></sec><sec id="s2c"><title>Scoring protocol</title><p>Evaluation of cases took place between July 1, 2016, and January 1, 2017, on a custom built web-based application. First, physicians were required to answer a preliminary survey regarding their usual clinical practice (supplementary table A1). Then for each case they were presented with the patient's history, findings on physical examination and standardised baseline clinical information, extracted from the patient electronic records (supplementary table A2). Physicians were provided the presentation high-resolution computed tomography scan (HRCT). The original HRCT report was not provided. We did not inform physicians if the host institution had performed surgical lung biopsy. Since biopsy decisions depend on a physician's individual clinical judgement, there would be no way of knowing which patients would eventually have undergone a lung biopsy. Also, if we had provided biopsy information, the clinical skill of the physician would be influenced by the expertise of the host institution.</p><p>The scoring protocol has been described previously [<xref rid="C15" ref-type="bibr">15</xref>]. For each case, physicians were required to select up to five differential diagnoses and provide a diagnostic likelihood (censored at 5% and summing to 100% in each case) from a drop-down menu of diffuse lung diseases (supplementary table A3) based upon their diagnostic confidence. The drop-down menu included a category labelled “other”, to be selected when the desired diagnosis was not listed. In this situation, physicians were required to provide their diagnosis in a free-text box. The only stipulation to scoring the cases was that each case was evaluated in isolation without interspecialty consultation.</p></sec><sec id="s2d"><title>Statistical analysis</title><p>Statistical analyses were performed using STATA (version 14, StataCorp, College Station, TX, USA). Data are given as means with standard deviations (<sc>sd</sc>), medians with interquartile range (IQR) or as the number of patients and percentage where appropriate. Group comparisons were made using the <italic>t</italic>-test, Wilcoxon rank sum, chi-squared statistics and Fisher's exact test where appropriate.</p><p>Cohen's kappa coefficient (κ) was used to evaluate interobserver agreement for diagnosis and the weighted kappa coefficient (κ<sub>w</sub>) was used to evaluate interobserver agreement for an estimation of the probability of each diagnosis. To do this, the percentage diagnostic likelihood given for each diagnosis was converted to a 5-point scale (0–4), representing clinically useful probabilities: 0=condition not included in the differential diagnosis, 1=low probability (5–25%), 2=intermediate probability (30–65%), 3=high probability (70–95%) and 4=pathognomonic (100%). This approach has been used in previous investigations of interobserver agreement for the diagnosis of diffuse lung diseases (supplementary material) [<xref rid="C15" ref-type="bibr">15</xref>–<xref rid="C17" ref-type="bibr">17</xref>]. Weighted kappa values were calculated between paired observers and expressed as median values with interquartile ranges for all unique combinations of pairs. Weighting the kappa coefficient allowed the degree of disagreement to be quantified by assigning greater emphasis to large differences between scores. Additionally, for each patient the first-choice diagnosis was considered high confidence if the diagnostic likelihood assigned was ≥70%. This distinction is based on the diagnostic likelihood categories used to assess the clinical probability of pulmonary embolism in the PIOPED study [<xref rid="C18" ref-type="bibr">18</xref>] and has been used in another study of diagnostic agreement [<xref rid="C15" ref-type="bibr">15</xref>].</p><p>We used outcome distinctions between IPF and other diffuse lung diseases to validate diagnostic accuracy for IPF by converting each physician's first-choice diagnosis into a binary IPF diagnosis category (IPF or not IPF). Cox proportional hazards modelling was then used to determine a hazard ratio (HR) for each physician, adjusted for disease severity by including per cent predicted <italic>D</italic><sub>LCO</sub> in the regression model. Time to death was the outcome for survival analyses and the survival period for each patient was calculated from the date of referral to the host institution to January 1, 2015. We tested the assumptions of proportional hazards by visual inspection of the log–log plot of survival, comparison of the Kaplan–Meier observed survival curves with the Cox predicted curves for the same variable and graphical and formal analysis of Schoenfeld residuals (analysis not shown). Results are reported as HR, 95% CI and p values. The prognostic accuracy of individual physician diagnoses was quantified using Harrell's C-index, which when used in this context, is a measure of prognostic discrimination (supplementary material) [<xref rid="C19" ref-type="bibr">19</xref>].</p><p>Multivariate linear regression models were used to identify independent predictors of prognostic accuracy within physician subgroups (expert, university, non-university and those with and without access to MDT meetings) taking the C-index as the dependent variable and using a backward elimination procedure, retaining variables with p<0·05. The assumptions of linear regression were tested and confirmed by inspection of residual-<italic>versus</italic>-predictor plots and heteroskedasticity was tested for graphically (by inspection of residuals plotted against fitted values) and non-graphically (using the Cook–Weisberg test for heteroskedasticity). The diagnostic performance of various subgroups of physicians based on these predictors was then compared to the expert panel group</p></sec></sec><sec sec-type="results" id="s3"><title>Results</title><sec id="s3a"><title>Patient population and participating physicians</title><p>The total cohort of cases was made up of 60 patients, including 22 (36.7%) with an MDT meeting diagnosis of IPF. Five patients required surgical lung biopsy. Three of these were diagnosed as IPF, one as pulmonary alveolar proteinosis and one as obliterative bronchiolitis. Vital status was known for all patients at the end of the study period. There were 26 out of 60 (43.4%) deaths at the end of the study period. Mean follow-up periods for IPF and non-IPF cases were 1246.0 days and 1646.0 days respectively. For more details of patient exclusions, diagnoses and mortality, see the supplementary material and supplementary table A4.</p><p>A total of 1141 respiratory physicians from 102 countries were invited to participate in the study. Between July 7, 2016, and January 1, 2017, 750 physicians representing 76 countries enrolled and completed the preliminary survey. Of these, 404 physicians, representing 57 countries, which included a panel of 34 invited experts, completed the evaluation of all 60 cases. Physicians who completed the study were more likely to be fellowship trained, work at university hospitals, have access to MDT meetings and diagnose more cases of IPF per month (<xref rid="TB1" ref-type="table">tables 1</xref> and <xref rid="TB2" ref-type="table">2</xref>). A summary of physician demographics based on country is shown in supplementary table A5.
<table-wrap id="TB1" orientation="portrait" position="float"><label>TABLE 1</label><caption><p>Responses to the preliminary survey by 404 physicians who completed the study and the 346 physicians who did not complete the study</p></caption><table frame="hsides" rules="groups"><colgroup span="1"><col align="left" span="1"></col><col align="center" span="1"></col><col align="center" span="1"></col><col align="center" span="1"></col></colgroup><thead><tr><td align="left" rowspan="1" colspan="1"><bold>Question</bold></td><td align="center" rowspan="1" colspan="1"><bold>Completed (n=404)</bold></td><td align="center" rowspan="1" colspan="1"><bold>Did not complete (n=346)</bold></td><td align="center" rowspan="1" colspan="1"><bold>p-value</bold></td></tr></thead><tbody><tr><td align="left" rowspan="1" colspan="1">Experience years</td><td align="center" rowspan="1" colspan="1">15.8</td><td align="center" rowspan="1" colspan="1">15.7</td><td align="center" rowspan="1" colspan="1">0.565</td></tr><tr><td align="left" rowspan="1" colspan="1">ILD Fellowship training</td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td></tr><tr><td align="left" rowspan="1" colspan="1"> Yes</td><td align="center" rowspan="1" colspan="1">359 (88.9%)</td><td align="center" rowspan="1" colspan="1">283 (70.0%)</td><td align="center" rowspan="1" colspan="1">0.006</td></tr><tr><td align="left" rowspan="1" colspan="1"> In-training</td><td align="center" rowspan="1" colspan="1">17 (4.2%)</td><td align="center" rowspan="1" colspan="1">20 (5.8%)</td><td align="center" rowspan="1" colspan="1">0.322</td></tr><tr><td align="left" rowspan="1" colspan="1"> No</td><td align="center" rowspan="1" colspan="1">28 (6.9%)</td><td align="center" rowspan="1" colspan="1">43 (12.4%)</td><td align="center" rowspan="1" colspan="1"></td></tr><tr><td align="left" rowspan="1" colspan="1">Hospital setting</td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td></tr><tr><td align="left" rowspan="1" colspan="1"> University</td><td align="center" rowspan="1" colspan="1">288 (71.3%)</td><td align="center" rowspan="1" colspan="1">207 (59.8%)</td><td align="center" rowspan="1" colspan="1">0.001</td></tr><tr><td align="left" rowspan="1" colspan="1"> Not university</td><td align="center" rowspan="1" colspan="1">116 (28.7%)</td><td align="center" rowspan="1" colspan="1">139 (40.2%)</td><td align="center" rowspan="1" colspan="1"></td></tr><tr><td align="left" rowspan="1" colspan="1">MDT meeting</td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td></tr><tr><td align="left" rowspan="1" colspan="1"> MDT meeting access</td><td align="center" rowspan="1" colspan="1">328 (81.2%)</td><td align="center" rowspan="1" colspan="1">247 (61.8%)</td><td align="center" rowspan="1" colspan="1">0.002</td></tr><tr><td align="left" rowspan="1" colspan="1"> No MDT meeting access</td><td align="center" rowspan="1" colspan="1">76 (18.8%)</td><td align="center" rowspan="1" colspan="1">99 (28.6%)</td><td align="center" rowspan="1" colspan="1"></td></tr><tr><td align="left" rowspan="1" colspan="1">Number of cases of IPF diagnosed/month</td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td></tr><tr><td align="left" rowspan="1" colspan="1"> None, we refer all cases of suspected IPF to an academic centre</td><td align="center" rowspan="1" colspan="1">20 (5.0%)</td><td align="center" rowspan="1" colspan="1">38 (11.0%)</td><td align="center" rowspan="1" colspan="1">0.002</td></tr><tr><td align="left" rowspan="1" colspan="1"> 1–10</td><td align="center" rowspan="1" colspan="1">337 (83.4%)</td><td align="center" rowspan="1" colspan="1">290 (83.8%)</td><td align="center" rowspan="1" colspan="1">0.883</td></tr><tr><td align="left" rowspan="1" colspan="1"> 11–20</td><td align="center" rowspan="1" colspan="1">37 (9.2%)</td><td align="center" rowspan="1" colspan="1">12 (3.5%)</td><td align="center" rowspan="1" colspan="1">0.002</td></tr><tr><td align="left" rowspan="1" colspan="1"> 20+</td><td align="center" rowspan="1" colspan="1">9 (2.2%)</td><td align="center" rowspan="1" colspan="1">5 (4.1%)</td><td align="center" rowspan="1" colspan="1">0.430</td></tr><tr><td align="left" rowspan="1" colspan="1">Access to specialist radiology expertise</td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td></tr><tr><td align="left" rowspan="1" colspan="1"> None</td><td align="center" rowspan="1" colspan="1">22 (5.4%)</td><td align="center" rowspan="1" colspan="1">26 (7.5%)</td><td align="center" rowspan="1" colspan="1">0.191</td></tr><tr><td align="left" rowspan="1" colspan="1"> Not directly but in my network</td><td align="center" rowspan="1" colspan="1">60 (14.9%)</td><td align="center" rowspan="1" colspan="1">58 (16.8%)</td><td align="center" rowspan="1" colspan="1">0.474</td></tr><tr><td align="left" rowspan="1" colspan="1"> Yes</td><td align="center" rowspan="1" colspan="1">322 (79.7%)</td><td align="center" rowspan="1" colspan="1">262 (75.7%)</td><td align="center" rowspan="1" colspan="1">0.248</td></tr><tr><td align="left" rowspan="1" colspan="1">Access to specialist pathology expertise</td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td></tr><tr><td align="left" rowspan="1" colspan="1"> None</td><td align="center" rowspan="1" colspan="1">34 (8.4%)</td><td align="center" rowspan="1" colspan="1">35 (10.1%)</td><td align="center" rowspan="1" colspan="1">0.006</td></tr><tr><td align="left" rowspan="1" colspan="1"> Not directly but in my network</td><td align="center" rowspan="1" colspan="1">85 (21.0%)</td><td align="center" rowspan="1" colspan="1">100 (28.9%)</td><td align="center" rowspan="1" colspan="1">0.013</td></tr><tr><td align="left" rowspan="1" colspan="1"> Yes</td><td align="center" rowspan="1" colspan="1">285 (70.5%)</td><td align="center" rowspan="1" colspan="1">211 (61.0%)</td><td align="center" rowspan="1" colspan="1">0.422</td></tr><tr><td align="left" rowspan="1" colspan="1">Availability of cryobiopsy</td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td></tr><tr><td align="left" rowspan="1" colspan="1"> Yes</td><td align="center" rowspan="1" colspan="1">65 (16.1%)</td><td align="center" rowspan="1" colspan="1">44 (12.7%)</td><td align="center" rowspan="1" colspan="1">0.191</td></tr><tr><td align="left" rowspan="1" colspan="1"> No</td><td align="center" rowspan="1" colspan="1">339 (83.9%)</td><td align="center" rowspan="1" colspan="1">302 (87.3%)</td><td align="center" rowspan="1" colspan="1"></td></tr></tbody></table><table-wrap-foot><p>ILD: interstitial lung disease; MDT: multidisciplinary team; IPF: idiopathic pulmonary fibrosis.</p></table-wrap-foot></table-wrap><table-wrap id="TB2" orientation="portrait" position="float"><label>TABLE 2</label><caption><p>Responses to the preliminary survey by 404 physicians grouped according to institution type (university hospital or not university hospital)</p></caption><table frame="hsides" rules="groups"><colgroup span="1"><col align="left" span="1"></col><col align="center" span="1"></col><col align="center" span="1"></col><col align="center" span="1"></col></colgroup><thead><tr><td align="left" rowspan="1" colspan="1"><bold>Grouping</bold></td><td align="center" rowspan="1" colspan="1"><bold>University hospital (n=288)</bold></td><td align="center" rowspan="1" colspan="1"><bold>Not university hospital (n=116)</bold></td><td align="center" rowspan="1" colspan="1"><bold>p-value</bold></td></tr></thead><tbody><tr><td align="left" rowspan="1" colspan="1">Experience years</td><td align="center" rowspan="1" colspan="1">14.9</td><td align="center" rowspan="1" colspan="1">17.8</td><td align="center" rowspan="1" colspan="1">0.009</td></tr><tr><td align="left" rowspan="1" colspan="1">Fellowship trained</td><td align="center" rowspan="1" colspan="1">251</td><td align="center" rowspan="1" colspan="1">108</td><td align="center" rowspan="1" colspan="1">0.085</td></tr><tr><td align="left" rowspan="1" colspan="1">MDT meeting practices</td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td></tr><tr><td align="left" rowspan="1" colspan="1"> No MDT meeting</td><td align="center" rowspan="1" colspan="1">41</td><td align="center" rowspan="1" colspan="1">35</td><td align="center" rowspan="1" colspan="1">0.001</td></tr><tr><td align="left" rowspan="1" colspan="1"> Daily MDT meeting</td><td align="center" rowspan="1" colspan="1">4</td><td align="center" rowspan="1" colspan="1">0</td><td align="center" rowspan="1" colspan="1">0.202</td></tr><tr><td align="left" rowspan="1" colspan="1"> Weekly MDT meeting</td><td align="center" rowspan="1" colspan="1">118</td><td align="center" rowspan="1" colspan="1">25</td><td align="center" rowspan="1" colspan="1">0.001</td></tr><tr><td align="left" rowspan="1" colspan="1"> Fortnightly MDT meeting</td><td align="center" rowspan="1" colspan="1">41</td><td align="center" rowspan="1" colspan="1">8</td><td align="center" rowspan="1" colspan="1">0.021</td></tr><tr><td align="left" rowspan="1" colspan="1"> Monthly MDT meeting</td><td align="center" rowspan="1" colspan="1">66</td><td align="center" rowspan="1" colspan="1">34</td><td align="center" rowspan="1" colspan="1">0.178</td></tr><tr><td align="left" rowspan="1" colspan="1"> Less than 1/month MDT meeting</td><td align="center" rowspan="1" colspan="1">18</td><td align="center" rowspan="1" colspan="1">14</td><td align="center" rowspan="1" colspan="1">0.05</td></tr><tr><td align="left" rowspan="1" colspan="1">Number of IPF cases diagnosed/month</td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td></tr><tr><td align="left" rowspan="1" colspan="1"> Refer all cases of suspected IPF</td><td align="center" rowspan="1" colspan="1">14</td><td align="center" rowspan="1" colspan="1">6</td><td align="center" rowspan="1" colspan="1">0.896</td></tr><tr><td align="left" rowspan="1" colspan="1"> 1–10 cases</td><td align="center" rowspan="1" colspan="1">234</td><td align="center" rowspan="1" colspan="1">103</td><td align="center" rowspan="1" colspan="1">0.065</td></tr><tr><td align="left" rowspan="1" colspan="1"> 11–20 cases</td><td align="center" rowspan="1" colspan="1">32</td><td align="center" rowspan="1" colspan="1">5</td><td align="center" rowspan="1" colspan="1">0.032</td></tr><tr><td align="left" rowspan="1" colspan="1"> 20+ cases</td><td align="center" rowspan="1" colspan="1">7</td><td align="center" rowspan="1" colspan="1">2</td><td align="center" rowspan="1" colspan="1">0.663</td></tr><tr><td align="left" rowspan="1" colspan="1">Access to radiology expertise</td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td></tr><tr><td align="left" rowspan="1" colspan="1"> Direct access</td><td align="center" rowspan="1" colspan="1">242</td><td align="center" rowspan="1" colspan="1">80</td><td align="center" rowspan="1" colspan="1">0.001</td></tr><tr><td align="left" rowspan="1" colspan="1"> Access through network</td><td align="center" rowspan="1" colspan="1">35</td><td align="center" rowspan="1" colspan="1">25</td><td align="center" rowspan="1" colspan="1">0.016</td></tr><tr><td align="left" rowspan="1" colspan="1"> No access</td><td align="center" rowspan="1" colspan="1">11</td><td align="center" rowspan="1" colspan="1">11</td><td align="center" rowspan="1" colspan="1">0.023</td></tr><tr><td align="left" rowspan="1" colspan="1">Access to pathology expertise</td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td></tr><tr><td align="left" rowspan="1" colspan="1"> Direct access</td><td align="center" rowspan="1" colspan="1">219</td><td align="center" rowspan="1" colspan="1">66</td><td align="center" rowspan="1" colspan="1">0.001</td></tr><tr><td align="left" rowspan="1" colspan="1"> Access through network</td><td align="center" rowspan="1" colspan="1">49</td><td align="center" rowspan="1" colspan="1">36</td><td align="center" rowspan="1" colspan="1">0.002</td></tr><tr><td align="left" rowspan="1" colspan="1"> No access</td><td align="center" rowspan="1" colspan="1">20</td><td align="center" rowspan="1" colspan="1">14</td><td align="center" rowspan="1" colspan="1">0.093</td></tr><tr><td align="left" rowspan="1" colspan="1">Cryobiopsy part of usual practice</td><td align="center" rowspan="1" colspan="1">54</td><td align="center" rowspan="1" colspan="1">11</td><td align="center" rowspan="1" colspan="1">0.022</td></tr></tbody></table><table-wrap-foot><p>MDT: multidisciplinary team; IPF: idiopathic pulmonary fibrosis.</p></table-wrap-foot></table-wrap></p></sec><sec id="s3b"><title>Frequency of IPF diagnosis and diagnostic confidence</title><p>A total of 24 240 case evaluations were performed (404 physicians×60 cases). IPF made up 6308 (26.0%) of all first-choice diagnoses. Of the IPF diagnoses, 72.3% were made with high confidence (diagnostic likelihood ≥70%). Expert panel members and academic physicians made high confidence diagnoses of IPF more frequently than non-academic physicians (p=0.002 and p=0.001, <xref rid="TB3" ref-type="table">table 3</xref>) and more frequently diagnosed IPF overall (p=0.005 and p=0.008, <xref rid="TB3" ref-type="table">table 3</xref>). Attendance at MDT meetings was not associated with a higher frequency of IPF diagnoses or a higher frequency of highly confident IPF diagnoses (p=0.718, p=0.925, <xref rid="TB3" ref-type="table">table 3</xref>).</p><table-wrap id="TB3" orientation="portrait" position="float"><label>TABLE 3</label><caption><p>Median number of idiopathic pulmonary fibrosis (IPF) diagnoses made and median number of high confidence IPF diagnoses made for individual physicians by subgroup</p></caption><table frame="hsides" rules="groups"><colgroup span="1"><col align="left" span="1"></col><col align="center" span="1"></col><col align="center" span="1"></col><col align="center" span="1"></col></colgroup><tbody><tr><td align="left" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"><bold>Expert panel physicians (n=34)</bold></td><td align="center" rowspan="1" colspan="1"><bold>Others (n=370)</bold></td><td align="center" rowspan="1" colspan="1"><bold>p-value</bold></td></tr><tr><td align="left" rowspan="1" colspan="1">Median number of IPF diagnoses</td><td align="center" rowspan="1" colspan="1">20 (IQR 14–23)</td><td align="center" rowspan="1" colspan="1">15 (IQR 11–19)</td><td align="center" rowspan="1" colspan="1">0.005</td></tr><tr><td align="left" rowspan="1" colspan="1">Median number of high confidence IPF diagnoses</td><td align="center" rowspan="1" colspan="1">17 (IQR 8–21)</td><td align="center" rowspan="1" colspan="1">11 (IQR 7–14)</td><td align="center" rowspan="1" colspan="1">0.002</td></tr><tr><td align="left" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"><bold>University hospital physicians (n=288)</bold></td><td align="center" rowspan="1" colspan="1"><bold>Not university hospital physicians (n=116)</bold></td><td align="center" rowspan="1" colspan="1"><bold>p-value</bold></td></tr><tr><td align="left" rowspan="1" colspan="1">Median number of IPF diagnoses</td><td align="center" rowspan="1" colspan="1">16 (IQR 12–20)</td><td align="center" rowspan="1" colspan="1">13 (IQR 10–19)</td><td align="center" rowspan="1" colspan="1">0.008</td></tr><tr><td align="left" rowspan="1" colspan="1">Median number of high confidence IPF diagnoses</td><td align="center" rowspan="1" colspan="1">11 (IQR 8–16)</td><td align="center" rowspan="1" colspan="1">9 (IQR 6–12)</td><td align="center" rowspan="1" colspan="1">0.001</td></tr><tr><td align="left" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"><bold>MDT meeting attendance (n=328)</bold></td><td align="center" rowspan="1" colspan="1"><bold>No MDT meeting attendance (n=76)</bold></td><td align="center" rowspan="1" colspan="1"><bold>p-value</bold></td></tr><tr><td align="left" rowspan="1" colspan="1">Median number of IPF diagnoses</td><td align="center" rowspan="1" colspan="1">15 (IQR 11–20)</td><td align="center" rowspan="1" colspan="1">15 (IQR 10–20)</td><td align="center" rowspan="1" colspan="1">0.925</td></tr><tr><td align="left" rowspan="1" colspan="1">Median number of high confidence IPF diagnoses</td><td align="center" rowspan="1" colspan="1">11 (IQR 7–15)</td><td align="center" rowspan="1" colspan="1">11 (IQR 6.5–15)</td><td align="center" rowspan="1" colspan="1">0.718</td></tr></tbody></table><table-wrap-foot><p>All values are out of 60 cases. High confidence diagnoses are defined as those cases assigned a diagnosis of IPF with a diagnostic likelihood of ≥70%. MDT: multidisciplinary team; IQR: interquartile range.</p></table-wrap-foot></table-wrap></sec><sec id="s3c"><title>Diagnostic agreement</title><p>Overall interobserver agreement for the first-choice diagnosis of IPF was moderate for the entire cohort of physicians (n=404, κ=0.42). Unweighted Kappa values for interobserver agreement for a diagnosis of IPF for various physician subgroups are shown in <xref rid="TB4" ref-type="table">table 4</xref>. The greatest diagnostic agreement for the first-choice diagnosis of IPF was between the expert panel members (n=34, κ=0.53). Physicians with no access to MDT meetings had the lowest level of diagnostic agreement for the first-choice diagnosis of IPF (n=76, κ=0.35) (<xref rid="TB4" ref-type="table">table 4</xref>). Agreement on the likelihood of an IPF diagnosis (ranging from <5% to >95%) was highest among expert physicians, academic physicians and physicians with access to MDT meetings (<xref rid="TB5" ref-type="table">table 5</xref>). Interobserver agreement for the likelihood of an IPF diagnosis between physicians based on country is shown in supplementary table A6.
<table-wrap id="TB4" orientation="portrait" position="float"><label>TABLE 4</label><caption><p>Unweighted kappa values (κ) for interobserver agreement for a diagnosis of idiopathic pulmonary fibrosis for various physician subgroups</p></caption><table frame="hsides" rules="groups"><colgroup span="1"><col align="left" span="1"></col><col align="center" span="1"></col></colgroup><thead><tr><td align="left" rowspan="1" colspan="1"><bold>Group</bold></td><td align="center" rowspan="1" colspan="1"><bold>Interobserver agreement (κ)</bold></td></tr></thead><tbody><tr><td align="left" rowspan="1" colspan="1">Physicians, expert panel (n=34)</td><td align="center" rowspan="1" colspan="1">0.53</td></tr><tr><td align="left" rowspan="1" colspan="1">Physicians, non expert panel (n=370)</td><td align="center" rowspan="1" colspan="1">0.41</td></tr><tr><td align="left" rowspan="1" colspan="1">University physicians (n=288)</td><td align="center" rowspan="1" colspan="1">0.43</td></tr><tr><td align="left" rowspan="1" colspan="1">Non-university physicians (n=116)</td><td align="center" rowspan="1" colspan="1">0.38</td></tr><tr><td align="left" rowspan="1" colspan="1">Physicians with MDT meeting access (n=328)</td><td align="center" rowspan="1" colspan="1">0.44</td></tr><tr><td align="left" rowspan="1" colspan="1">Physicians without MDT meeting access (n=76)</td><td align="center" rowspan="1" colspan="1">0.35</td></tr></tbody></table><table-wrap-foot><p>MDT: multidisciplinary team.</p></table-wrap-foot></table-wrap><table-wrap id="TB5" orientation="portrait" position="float"><label>TABLE 5</label><caption><p>Comparisons of weighted kappa values (κ<sub>w</sub>) for interobserver agreement on the diagnostic likelihood of a diagnosis of idiopathic pulmonary fibrosis between various subgroups</p></caption><table frame="hsides" rules="groups"><colgroup span="1"><col align="left" span="1"></col><col align="center" span="1"></col><col align="center" span="1"></col></colgroup><thead><tr><td align="left" rowspan="1" colspan="1"><bold>Group comparisons</bold></td><td align="center" rowspan="1" colspan="1"><bold>Interobserver agreement (κ<sub>w</sub>)</bold></td><td align="center" rowspan="1" colspan="1"><bold>p</bold></td></tr></thead><tbody><tr><td align="left" rowspan="1" colspan="1">Physicians, expert panel (n=34)</td><td align="center" rowspan="1" colspan="1">0.65 (IQR 0.53–0.72)</td><td align="center" rowspan="2" colspan="1"><0.001</td></tr><tr><td align="left" rowspan="1" colspan="1">Remaining physician group (n=370)</td><td align="center" rowspan="1" colspan="1">0.53 (IQR 0.41–0.63)</td></tr><tr><td align="left" rowspan="1" colspan="1">University hospital physicians (n=288)</td><td align="center" rowspan="1" colspan="1">0.56 (IQR 0.45–0.65)</td><td align="center" rowspan="2" colspan="1"><0.001</td></tr><tr><td align="left" rowspan="1" colspan="1">Non-university hospital physicians (n=116)</td><td align="center" rowspan="1" colspan="1">0.49 (IQR 0.38–0.59)</td></tr><tr><td align="left" rowspan="1" colspan="1">MDT meeting available (n=328)</td><td align="center" rowspan="1" colspan="1">0.56 (IQR 0.45–0.65)</td><td align="center" rowspan="2" colspan="1"><0.001</td></tr><tr><td align="left" rowspan="1" colspan="1">No MDT meeting available (n=76)</td><td align="center" rowspan="1" colspan="1">0.46 (IQR 0.33–0.58)</td></tr></tbody></table><table-wrap-foot><p>MDT: multidisciplinary team.</p></table-wrap-foot></table-wrap></p></sec><sec id="s3d"><title>Prognostic accuracy of an IPF diagnosis</title><p>Diagnoses of IPF were prognostically significant for 318 of 404 respiratory physicians (68.6%, median HR 2.81, IQR 2.21–3.61; median C-index=0.72, IQR 0.70–0.74). The range of C-indices across the entire cohort of physicians was 0.69–0.81. Hazards ratios, p values and C-indices for all participating physicians based on country are shown in supplementary table A7. Expert physicians, compared to other physicians, were more likely to make prognostically significant IPF diagnoses (29/34, 85.2%, <italic>versus</italic> 246/370, 66.4%; p=0.02) and with greater prognostic discrimination (as judged by C-indices), p=0.0002 (supplementary table A8). Academic physicians demonstrated greater prognostic discrimination for a diagnosis of IPF than non-university based hospital physicians, p=0.0006 (supplementary table A9). Physicians who attend MDT meetings demonstrated greater prognostic discrimination for a diagnosis of IPF than physicians not attending MDT meetings, p=0.004, supplementary table A10).</p><p>Multivariate linear regression analysis was performed taking the C-index as the dependent variable and 1) academic status, 2) years of experience (stratified by thresholds ranging from 5–35 years in 5-year increments), 3) MDT meeting attendance and 4) the number of IPF cases diagnosed per month as the independent variables. Academic status, >20 years of experience and attendance at MDT meetings independently predicted the prognostic accuracy of IPF diagnosis (supplementary table A11). Subsequent analyses of particular interest are summarised in <xref rid="TB6" ref-type="table">table 6</xref>. Specifically, 1) university hospital physicians with >20 years of experience achieved equivalent prognostic discrimination to the expert panel for a diagnosis of IPF (or not IPF group), regardless of attendance at weekly MDT meetings (<xref rid="TB6" ref-type="table">table 6</xref>, supplementary figure A2); 2) non-university hospital physician prognostic discrimination did not reach that of the expert panel, regardless of availability of MDT meetings or the threshold of 20 years of experience (<xref rid="TB6" ref-type="table">table 6</xref>, supplementary figure A2); 3) however, non-university hospital physicians with >20 years of experience, attending <italic>weekly</italic> MDT meetings, demonstrated near expert level prognostic accuracy (C-index 0.72, IQR 0.70–0.72; p=0.052).</p><table-wrap id="TB6" orientation="portrait" position="float"><label>TABLE 6</label><caption><p>Prognostic accuracy expressed as the C-index for diagnosis of idiopathic pulmonary fibrosis (IPF) or not IPF given by various physician subgroups.</p></caption><table frame="hsides" rules="groups"><colgroup span="1"><col align="left" span="1"></col><col align="center" span="1"></col><col align="center" span="1"></col><col align="left" span="1"></col><col align="center" span="1"></col><col align="center" span="1"></col></colgroup><thead><tr><td align="left" colspan="3" rowspan="1"><bold>University hospital physicians</bold></td><td align="center" colspan="3" rowspan="1"><bold>Non-university hospital physicians</bold></td></tr><tr><td align="left" rowspan="1" colspan="1"><bold>Group</bold></td><td align="center" rowspan="1" colspan="1"><bold>C-index</bold></td><td align="center" rowspan="1" colspan="1"><bold>p-value</bold></td><td align="center" rowspan="1" colspan="1"><bold>Group</bold></td><td align="center" rowspan="1" colspan="1"><bold>C-index</bold></td><td align="center" rowspan="1" colspan="1"><bold>p-value</bold></td></tr></thead><tbody><tr><td align="left" rowspan="1" colspan="1">>20 years of experience, no MDT meeting (n=11)</td><td align="center" rowspan="1" colspan="1">0.72 (0.70–0.73)</td><td align="center" rowspan="1" colspan="1">0.229</td><td align="left" rowspan="1" colspan="1">>20 years of experience, no MDT meeting (n=18)</td><td align="center" rowspan="1" colspan="1">0.70 (0.70–0.73)</td><td align="center" rowspan="1" colspan="1">0.008</td></tr><tr><td align="left" rowspan="1" colspan="1">>20 years of experience, MDT meeting (n=51)</td><td align="center" rowspan="1" colspan="1">0.72 (0.71–0.75)</td><td align="center" rowspan="1" colspan="1">0.116</td><td align="left" rowspan="1" colspan="1">>20 years of experience, MDT meeting (n=24)</td><td align="center" rowspan="1" colspan="1">0.71 (0.70–0.73)</td><td align="center" rowspan="1" colspan="1">0.019</td></tr><tr><td align="left" rowspan="1" colspan="1"><20 years of experience, no MDT meeting (n=30)</td><td align="center" rowspan="1" colspan="1">0.71 (0.70–0.72)</td><td align="center" rowspan="1" colspan="1"><0.001</td><td align="left" rowspan="1" colspan="1"><20 years of experience, no MDT meeting (n=17)</td><td align="center" rowspan="1" colspan="1">0.70 (0.70–0.71)</td><td align="center" rowspan="1" colspan="1"><0.001</td></tr><tr><td align="left" rowspan="1" colspan="1"><20 years of experience, MDT meeting (n=167)</td><td align="center" rowspan="1" colspan="1">0.72 (0.70–0.74)</td><td align="center" rowspan="1" colspan="1">0.001</td><td align="left" rowspan="1" colspan="1"><20 years of experience, MDT meeting (n=52)</td><td align="center" rowspan="1" colspan="1">0.71 (0.69–0.72)</td><td align="center" rowspan="1" colspan="1"><0.001</td></tr></tbody></table><table-wrap-foot><p>p-values are based upon a group comparison with the expert panel (n=34, C-index=0.74 (0.72–0.75)). MDT=multidisciplinary team.</p></table-wrap-foot></table-wrap></sec></sec><sec sec-type="discussion" id="s4"><title>Discussion</title><p>Our results show that academic status, attendance at MDT meetings and experience level of physicians are independently associated with greater prognostic discrimination between diagnoses of IPF and other ILDs. In particular, using mortality to validate accuracy of IPF diagnosis, we have shown that accuracy of IPF diagnosis made by university hospital-based practitioners with greater than 20 years of experience is equivalent to that of international IPF experts.</p><p>A recent study reported near parity in diagnostic agreement and accuracy for IPF between expert physicians and their respective MDT meetings [<xref rid="C15" ref-type="bibr">15</xref>]. The purpose of this study was to investigate whether these findings could also be applied to physicians of varying levels of experience when acting in isolation without the benefit of MDT meeting evaluation. A central feature of our study was that we validated IPF diagnosis against mortality, an approach used in a previous study of diagnostic agreement and accuracy in IPF [<xref rid="C15" ref-type="bibr">15</xref>]. In diffuse lung disease, multidisciplinary discussion is the recommended approach to diagnosis, which involves integrating all available clinical, radiologic and if available, pathologic data. For this reason, there is no reference standard against which the veracity of MDT diagnosis can be tested. However, as a poor outcome is a cardinal feature of IPF, accurate diagnosis should, in principle, provide the greatest prognostic discrimination between IPF and other ILDs.</p><p>The use of the C-index to examine prognostic accuracy between physician subgroups warrants further discussion. The range of achievable C indices for the 404 clinicians was narrow (from 0.69 to 0.81, therefore representing a 13-point scale) and is likely to reflect the fact that some non-IPF patients do badly and so misclassification of a non-IPF patient as an IPF patient might not significantly impact the C-index. Given this outcome overlap between the two disease groups, apparently small cohort shifts are likely to be more meaningful than they appear. Furthermore, as an example, the difference between a C-index of 0.70 and 0.72 is 15.4%, representing an upward shift in prognostic accuracy of 15.4% when comparing a population of experienced academic clinicians with MDT access to a population of less experienced (<20 years) non-academic clinicians without MDT access. This is in fact a large difference when, for example, it is compared with cohort shifts in serial forced vital capacity (FVC) in IPF antifibrotic trials, put up against the range of baseline FVC values.</p><p>Although several studies have reported that MDT diagnosis is associated with higher levels of diagnostic confidence and superior interobserver agreement when compared with the individual components of the MDT in isolation [<xref rid="C15" ref-type="bibr">15</xref>, <xref rid="C20" ref-type="bibr">20</xref>, <xref rid="C21" ref-type="bibr">21</xref>], the effect that MDT meetings have on individuals has not been examined. One of the assumed benefits of a multidisciplinary approach to IPF diagnosis is that those participating have their diagnostic thinking subjected to peer scrutiny. The regular interspecialty discussion that MDT meetings promote is likely to broaden a physician's experience and establish an ethos of debate and critical evaluation. Conceivably, physicians who are accustomed to this process gain skill in related disciplines such as HRCT interpretation, which they can use outside the multidisciplinary setting. For some physicians, increasing patient numbers and possibly referrals from other centres will mean that full MDT meeting characterisation is possible only for selected cases. Therefore, just as in this study, it is likely that a substantial number of IPF patients will receive a diagnosis made by their respiratory physician acting in isolation. In a recent national survey conducted in France, IPF diagnosis resulted from multidisciplinary discussion in only 50% of cases [<xref rid="C22" ref-type="bibr">22</xref>]. It is noteworthy that in the current study, 43% of completing physicians stated that in most cases of suspected IPF, they made the diagnosis by themselves with the aid of diagnostic guidelines. We demonstrate that weekly MDT meeting attendance among experienced non-university hospital physicians increased prognostic accuracy of IPF diagnosis to that achieved by IPF experts.</p><p>Our findings may have implications for future multidisciplinary practice. Based on several studies of diagnostic agreement and accuracy over the past decade, MDT evaluation of IPF has become enshrined in the literature as the optimum approach to diagnostic synthesis [<xref rid="C1" ref-type="bibr">1</xref>, <xref rid="C12" ref-type="bibr">12</xref>, <xref rid="C13" ref-type="bibr">13</xref>, <xref rid="C15" ref-type="bibr">15</xref>, <xref rid="C20" ref-type="bibr">20</xref>, <xref rid="C23" ref-type="bibr">23</xref>, <xref rid="C24" ref-type="bibr">24</xref>]. A difficulty implementing this recommendation is that local access to multidisciplinary expertise may be limited. One possible solution to this problem is to network with academic centres using different forms of telemedicine. Since the web-based evaluation of patients in this study to some extent replicates telemedicine methodologies, our findings provide support for telemedicine as an acceptable form of multidisciplinary practice [<xref rid="C24" ref-type="bibr">24</xref>, <xref rid="C25" ref-type="bibr">25</xref>]. Such collaboration could also include guidance on setting up local community hospital MDT meetings or having community physicians attend MDT meetings at local university hospitals.</p><p>Our study has some unavoidable limitations, common to previous studies of multidisciplinary practice [<xref rid="C15" ref-type="bibr">15</xref>–<xref rid="C17" ref-type="bibr">17</xref>]. First, unlike real-world clinical practice, it was impractical for physicians to engage in face-to-face consultation with patients, meaning that doctors did not have the chance to take a clinical history or examine the patients themselves. In complex disease, direct contact with the patient may influence a clinician's impression in a manner that is not easy to quantify objectively. However, direct patient contact in a study of this size would have been impracticable. Our methodology of web-based case reviews is instead similar to that of previously published studies of diagnostic agreement and accuracy between MDT meetings [<xref rid="C15" ref-type="bibr">15</xref>, <xref rid="C20" ref-type="bibr">20</xref>, <xref rid="C26" ref-type="bibr">26</xref>]. Second, physicians who completed the study were more likely to be fellowship trained, work at university institutions, attend MDT meetings and diagnose more cases of IPF per month. Nevertheless, sufficient numbers of physicians working in non-university institutions and without access to MDT meetings took part in our study, allowing us to perform statistically meaningful analyses in these subgroups. Third, to our knowledge no guideline recommendation indicates what precisely constitutes a valid MDT meeting. Although we asked physicians if they participated in formal MDT meetings, we did not attempt to quantify informal interspecialty consultation, which might also be considered by some to be a form of multidisciplinary practice [<xref rid="C25" ref-type="bibr">25</xref>]. An investigation to identify the optimum MDT meeting format could be the focus of future investigations. Fourth, although poor outcome separates IPF from other ILDs, the natural history of IPF is heterogeneous and therefore there is likely to be some overlap between the two disease groupings (IPF <italic>versus</italic> not IPF). Finally, although our selection of cases from 2010 meant that mortality differences between patients with IPF and other ILDs were not confounded by treatment with antifibrotic therapy, we did not evaluate the potential confounding influences of immunosuppressive therapy (which may be harmful in IPF patients) on mortality.</p><p>In conclusion, our study indicates that diagnostic agreement for IPF is acceptable among a large group of respiratory physicians of varying degrees of experience and drawn from a wide range of geographic locations. However, experienced respiratory doctors who work at university-based institutions show greater agreement on a diagnosis of IPF and make greater prognostic distinctions between IPF and other diffuse lung diseases than those at non-university institutions. Importantly, the diagnostic performance of experienced non-university practitioners improves with regular MDT meetings. These results may be a stimulus for greater interaction between university and community hospitals as well as the development of local MDT meetings for the specific purpose of assessing patients with suspected IPF.</p></sec><sec id="s5"><title>Supplementary material</title><supplementary-material content-type="local-data" id="supplementary"><object-id pub-id-type="doi">10.1183/13993003.00936-2017.Supp1</object-id><p><bold>Please note:</bold> supplementary material is not edited by the Editorial Office, and is uploaded as it has been supplied by the author.</p><p>Supplementary material <inline-supplementary-material id="SS1" mimetype="application" mime-subtype="pdf" xlink:href="ERJ-00936-2017_Supplement.pdf" content-type="local-data">ERJ-00936-2017_Supplement</inline-supplementary-material></p></supplementary-material></sec><sec id="s6"><title>Disclosures</title><supplementary-material content-type="local-data" id="disclosures"><object-id pub-id-type="doi">10.1183/13993003.00936-2017.Supp2</object-id><p>J. Behr <inline-supplementary-material id="SS2" mimetype="application" mime-subtype="pdf" xlink:href="ERJ-00936-2017_Behr.pdf" content-type="local-data">ERJ-00936-2017_Behr</inline-supplementary-material></p><p>K. Brown <inline-supplementary-material id="SS3" mimetype="application" mime-subtype="pdf" xlink:href="ERJ-00936-2017_Brown.pdf" content-type="local-data">ERJ-00936-2017_Brown</inline-supplementary-material></p><p>V. Cottin <inline-supplementary-material id="SS4" mimetype="application" mime-subtype="pdf" xlink:href="ERJ-00936-2017_Cottin.pdf" content-type="local-data">ERJ-00936-2017_Cottin</inline-supplementary-material></p><p>B. Crestani <inline-supplementary-material id="SS5" mimetype="application" mime-subtype="pdf" xlink:href="ERJ-00936-2017_Crestani.pdf" content-type="local-data">ERJ-00936-2017_Crestani</inline-supplementary-material></p><p>K. Flaherty <inline-supplementary-material id="SS6" mimetype="application" mime-subtype="pdf" xlink:href="ERJ-00936-2017_Flaherty.pdf" content-type="local-data">ERJ-00936-2017_Flaherty</inline-supplementary-material></p><p>I. Glaspole <inline-supplementary-material id="SS7" mimetype="application" mime-subtype="pdf" xlink:href="ERJ-00936-2017_Glaspole.pdf" content-type="local-data">ERJ-00936-2017_Glaspole</inline-supplementary-material></p><p>D. Hansell <inline-supplementary-material id="SS8" mimetype="application" mime-subtype="pdf" xlink:href="ERJ-00936-2017_Hansell.pdf" content-type="local-data">ERJ-00936-2017_Hansell</inline-supplementary-material></p><p>K. Johannson <inline-supplementary-material id="SS9" mimetype="application" mime-subtype="pdf" xlink:href="ERJ-00936-2017_Johannson.pdf" content-type="local-data">ERJ-00936-2017_Johannson</inline-supplementary-material></p><p>M. Kolb <inline-supplementary-material id="SS10" mimetype="application" mime-subtype="pdf" xlink:href="ERJ-00936-2017_Kolb.pdf" content-type="local-data">ERJ-00936-2017_Kolb</inline-supplementary-material></p><p>Y. Kondoh <inline-supplementary-material id="SS11" mimetype="application" mime-subtype="pdf" xlink:href="ERJ-00936-2017_Kondoh.pdf" content-type="local-data">ERJ-00936-2017_Kondoh</inline-supplementary-material></p><p>M. Kreuter <inline-supplementary-material id="SS12" mimetype="application" mime-subtype="pdf" xlink:href="ERJ-00936-2017_Kreuter.pdf" content-type="local-data">ERJ-00936-2017_Kreuter</inline-supplementary-material></p><p>T. Maher <inline-supplementary-material id="SS13" mimetype="application" mime-subtype="pdf" xlink:href="ERJ-00936-2017_Maher.pdf" content-type="local-data">ERJ-00936-2017_Maher</inline-supplementary-material></p><p>F. Martinez <inline-supplementary-material id="SS14" mimetype="application" mime-subtype="pdf" xlink:href="ERJ-00936-2017_Martinez.pdf" content-type="local-data">ERJ-00936-2017_Martinez</inline-supplementary-material></p><p>H. Nunes <inline-supplementary-material id="SS15" mimetype="application" mime-subtype="pdf" xlink:href="ERJ-00936-2017_Nunes.pdf" content-type="local-data">ERJ-00936-2017_Nunes</inline-supplementary-material></p><p>G. Raghu <inline-supplementary-material id="SS16" mimetype="application" mime-subtype="pdf" xlink:href="ERJ-00936-2017_Raghu.pdf" content-type="local-data">ERJ-00936-2017_Raghu</inline-supplementary-material></p><p>L. Richeldi <inline-supplementary-material id="SS17" mimetype="application" mime-subtype="pdf" xlink:href="ERJ-00936-2017_Richeldi.pdf" content-type="local-data">ERJ-00936-2017_Richeldi</inline-supplementary-material></p><p>C. Ryerson <inline-supplementary-material id="SS18" mimetype="application" mime-subtype="pdf" xlink:href="ERJ-00936-2017_Ryerson.pdf" content-type="local-data">ERJ-00936-2017_Ryerson</inline-supplementary-material></p><p>P. Spagnolo <inline-supplementary-material id="SS19" mimetype="application" mime-subtype="pdf" xlink:href="ERJ-00936-2017_Spagnolo.pdf" content-type="local-data">ERJ-00936-2017_Spagnolo</inline-supplementary-material></p><p>S. Tomassetti <inline-supplementary-material id="SS20" mimetype="application" mime-subtype="pdf" xlink:href="ERJ-00936-2017_Tomassetti.pdf" content-type="local-data">ERJ-00936-2017_Tomassetti</inline-supplementary-material></p><p>D. Valeyre <inline-supplementary-material id="SS21" mimetype="application" mime-subtype="pdf" xlink:href="ERJ-00936-2017_Valeyre.pdf" content-type="local-data">ERJ-00936-2017_Valeyre</inline-supplementary-material></p><p>C. Vancheri <inline-supplementary-material id="SS22" mimetype="application" mime-subtype="pdf" xlink:href="ERJ-00936-2017_Vancheri.pdf" content-type="local-data">ERJ-00936-2017_Vancheri</inline-supplementary-material></p><p>S. Walsh <inline-supplementary-material id="SS23" mimetype="application" mime-subtype="pdf" xlink:href="ERJ-00936-2017_Walsh.pdf" content-type="local-data">ERJ-00936-2017_Walsh</inline-supplementary-material></p><p>M. Wijsenbeek <inline-supplementary-material id="SS24" mimetype="application" mime-subtype="pdf" xlink:href="ERJ-00936-2017_Wijsenbeek.pdf" content-type="local-data">ERJ-00936-2017_Wijsenbeek</inline-supplementary-material></p><p>W. Wuyts <inline-supplementary-material id="SS25" mimetype="application" mime-subtype="pdf" xlink:href="ERJ-00936-2017_Wuyts.pdf" content-type="local-data">ERJ-00936-2017_Wuyts</inline-supplementary-material></p></supplementary-material></sec></body><back><ack><title>Acknowledgements</title><p>Members of the IPF Project Consortium are as follows: Ping Shi Zhu, Yiming Yuan, Cesar Yoshito Fukuda, Yuki Yoshimatsu, Antoni Xaubet, Ai Ming Wong, Peter White, Gloria Westney, Alex West, Thomas Wessendorf, Yuko Waseda, Chingyu Wang, Jose Maria Vienna, Jelica Videnovic Ivanov, Vanesa Vicens Zygmunt, Maria Del Carmen Venero Caceres, Gerson Velásquez Pinto, Elizabeth Veitch, Martina Vasakova, Francesco Varone, Brenda Elena Varela, Peter Van Hal, Marjo Van De Ven, Ivo Van Der Lee, Leon Van Den Toorn, Amaia Urrutia Gajate, Ján Urban, Luis Gonzalo Ugarte Fornell, Argyrios Tzouvelekis, Kevin Twohig, Alice Turner, Sergio Trujillo, Antonio Triani, Daniel Traila, Veronica Torres, Hiromi Tomioka, Keisuke Tomii, Rade Tomic, Claudia Toma, Fatma Tokgoz Akyil, Kazunori Tobino, Ricardo Tobar, Anupama Tiwari, Regina Tibana, Xinlun Tian, Muhunthan Thillai, Weiping Tham, Felicia Teo, Jasna Tekavec Trkanjec, Paulo Teixeira, David Tarpey, Leonidas Tapias, Kiminobu Tanizawa, Yoshinori Tanino, Toshinori Takada, Gabriela Tabaj, Erzsebet Szolnoki, Rajesh Swarnakar, Irina Strambu, Martina Sterclova, Katherine Spinks, Chun Ian Soo, Amir Soltani, Sonam Solanki, Eman Sobh, Maria Raquel Soares, Jan Smith, Brian Smith, Philip Slocum, Hans Slabbynck, Ilya Sivokozov, Adrian Shifren, Shih Min Shen, Charles Sharp, Aruna Shanmuganathan, Alfredo Sebastiani, Simone Scarlata, Recep Savas, Shinichi Sasaki, Joanna Santeliz, Alfredo N.C. Santana, Rafaela Sanchez, Mauricio Salinas, Shigeki Saito, Frank Ryan, Juan Antonio Royo Prats, Elisabetta Rosi, Haala Rokadia, Alejandro Robles Perez, Pilar Rivera Ortega, Maite Rio Ramirez, Stefano Righetti, Cristina Reichner, Claudia Ravaglia, Pailin Ratanawatkul, Vijaya Ramalingam, Arvind Rajasekaran, Elzbieta Radzikowska, Seung Won Ra, Silvia Quadrelli, Juan Precerutti, Jyotika Prasad, Daniel Popa, Silvia Pizzolato, Wojciech Piotrowski, Andres Pineiro, Davide Piloni, Tatjana Peroš Golubičić, Rafael Perez, Carlos Pereira, Brett Pereira, Michael Perch, Nina Patel, Dharmesh Patel, Ilias Papanikolaou, Despina Papakosta, Efstratios Panselinas, Yong Kek Pang, Priyada Pandya, Eva Padrão, Ozlem Ozdemir Kumbasar, Maria J. Overbeek, Armine Otto Minasian, Deirdre O'Riordan, Josuel Ora, Justin Oldham, Oguzhan Okutan, Shinichiro Ohshimo, I.Kivilcim Oguzulgen, Takashi Ogura, Timothy O'Donnell, Conor O'Dochartaigh, Sarah O'Beirne, Mario Nunes, Lubov Novikova, Luca Novelli, Imre Noth, Nilson Nogueira Mendes Neto, Mitra Niroumand, Asunción Nieto, Alexandra Neves, Anoop Nambiar, Sudhir Nair, Rufai Nadama, Eoin Murtagh, Marco Mura, Joachim Müller Quernheim, Ansuman Mukhopadhyay, Suranjan Mukherjee, Julie Morisset, Onofre Moran, Joshua Mooney, Janne Møller, Nesrin Mogulkoc, Atsushi Miyamoto, Branislava Milenkovic, Stephen Mette, Mayra Mejia, Federico Mei, Mariano Mazzei, Toshiaki Matsuda, Carol Mason, Manuela Martínez Francés, George Margaritopoulos, Silvina Mannarino, Eliane Mancuzo, Foteini Malli, Puneet Malhotra, Martin Maillo, Jose Maia, Masoud Mahdavian, Flemming Madsen, Tracy Luckhardt, William Lucht, Su Ying Low, Concepcion Patricia Lopez Miguel, Randolph Lipchik, Steven Levy, Kovi Levin, Kai Ling Lee, David Lederer, Matthew Lammi, Hoi Yee Kwan, Sandeep Kukreja, Anuk Kruavit, Vasilis Kouranos, Mateusz Kotecki, Likurgos Kolilekas, Maria Kokosi, Heiko Knoop, Esen Kiyan, Tomoo Kishaba, Melissa King Biggs, Yet H Khor, Ayaz Khan, Nasreen Khalil, Ravindra Kedia, Naomi Kebba, Leticia Kawano Dourado, Kent Kapitan, Chung Dann Kan, Ali Fuat Kalyoncu, Meena Kalluri, Yasemin Kabasakal, Soma Jyothula, Maria Antonia Juretschke, Eoin Judge, Dragana Jovanovic, René Jonkers, Helen Jo, Shinyu Izumi, Haruyuki Ishii, Satoshi Ikeda, Aishah Ibrahim, Abdalla Ibrahim, Arfian Ibrahim, Charlotte Hyldgaard, Gary Hunninghake, Tristan Huie, Alison Hufton, Xiaowen Hu, Wan Chin Hsieh, Rodrigo Hoyos, Rachel Hoyles, Omar Holguin Rodriguez, Marie Pier Hogan, Ulla Hodgson, Helen Hilkin Sogoloff, Edwin Herrera, Brandon Michael Henry, Merel Hellemons, Ana Hecimovic, Ryuji Hayashi, Simon Hart, Sergio Harari, Sarah Haney, Nathan Hambly, Rismon Hakkim, Mónica Gutiérrez, Ria Gripaldo, Alejandro Gomez, Nicole Goh, Raul Godoy, Christopher Gilbert, Ioannis Giannarakis, Stefano Gasparini, Puneet Garcha, Sofia Furtado, Alessandro Fois, Patrick Flood Page, Sophie Fletcher, Elie Fiss, Juan Figueroa Casas, Marcelo Figueroa Casas, Christine A. 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