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American Journal of Critical Care. 2004;13: 169-170
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The authors reply
We appreciate the comments regarding our recent article, titled "Evaluation of Chemical Dot Thermometers in Orally Intubated Patients" (September 2003:403–408). We regret the inconsistency caused by our reference to clinically significant differences of 0.3°C in discussing a priori power and ≥ 0.4°C in discussing the results of Erickson et al1 as well as our own. Our intent was to focus on the latter definition of clinical significance.

The inclusion of limits of agreement (LOA) data would have enhanced our discussion of bias. Examination of the LOA with a Bland-Altman plot with LOA lines at ±0.62°C reveals only 3 cases (3.5%) falling outside the 95% LOA bounds and no apparent trend in extreme values in relation to estimated true temperature (average of chemical dot and electronic readings). Several other comparisons of bias in relation to the average temperature also revealed no trend. These included the computation of the Spearman correlation of the absolute value of the bias with the average temperature2 (rs = –0.06) and a comparison of means of standard deviations for both bias and absolute bias for each of the 3 ranges of average temperature (35°C–36.99°C, 37°C–38.99°C, and ≥ 39°C). Bias data showed only small deviations from normality, and, as Bland and Altman indicated, "...a non-normal distribution of differences may not be as serious here [in LOA analysis] as in other statistical contexts."2

What is most salient is that the 95% LOA bounds (±0.062°C) exceed our clinically significant differences (±0.04°C). This negates a claim of equivalence; however, our results and discussion do not make such a claim. Our discussion regarding possible temperature underestimation with the chemical dot thermometers, our recommendation of their use as a screening tool with subsequent confirmation with an electronic thermometer when temperature measurements have important consequences for treatment decision making, and our caveat regarding the potential for user variability are appropriate cautions.

Patricia Potter, RN, PhD, CMAC, Marilyn Schallom, RN, MSN, CCRN, CCNS, Susan Davis, RN, MSN, BC, CS-MSCNS, CCRN, Carrie Sona, RN, MSN, CCRN, CS-MSCNS and Maryellen McSweeney, PhD
REFERENCES

  1. Erickson RS, Meyer LT, Woo TM. Accuracy of chemical dot thermometers in critically ill adults and young children. Image J Nurs Sch. Spring 1996;219:23–28.
  2. Bland JM, Altman DG. Measuring agreement in method comparison studies. Stat Methods Med Res. 1999;8:135–160.[Abstract/Free Full Text]




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