Bench-to-bedside review: The importance of the precision of the reference technique in method comparison studies--with specific reference to the measurement of cardiac output
Open accessAbstract
Bland-Altman analysis is used for assessing agreement between two measurements of the same clinical variable. In the field of cardiac output monitoring, its results, in terms of bias and limits of agreement, are often difficult to interpret, leading clinicians to use a cutoff of 30% in the percentage error in order to decide whether a new technique may be considered a good alternative. This percentage error of +/- 30% arises from the assumption that the commonly used reference technique, intermittent thermodilution, has a precision of +/- 20% or less. The combination of two precisions of +/- 20% equates to a total error of +/- 28.3%, which is commonly rounded up to +/- 30%. Thus, finding a percentage error of less than +/- 30% should equate to the new tested technique having an error similar to the reference, which therefore should be acceptable. In a worked example in this paper, we discuss the limitations of this approach, in particular in regard to the situation in which the reference technique may be either more or less precise than would normally be expected. This can lead to inappropriate conclusions being drawn from data acquired in validation studies of new monitoring technologies. We conclude that it is not acceptable to present comparison studies quoting percentage error as an acceptability criteria without reporting the precision of the reference technique.
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Echocardiography shows a precision error of around 30% when compared to gold standard dilution techniques, which falls within the clinically accepted range.
“For instance, echocardiography shows a precision error of around 30% when compared to gold standard dilution techniques, which falls within the clinically accepted range [54,55].”
From Trends and Challenges in Noninvasive Hemodynamic Monitoring of Neonates Following Cardiac Surgery: A Narrative Review (2025) · cites this paper as [55]
The Validation of cardiac output monitoring devices section (page unavailable) describes ±30% as a commonly used percentage-error cutoff for comparing a new cardiac-output technique with intermittent thermodilution. It does not report that echocardiography has a 30% error; it also warns that the cutoff alone cannot establish clinical acceptability without measuring the reference technique’s precision. (LLM, conf=0.88)
Experimental — accuracy not yet measuredSimilar associations between inflammatory mediators and disease severity have been demonstrated in the context of influenza virus, coronavirus, and parainfluenza virus infections.
“Similar associations have been demonstrated in the context of influenza virus (21, 43, 206, 283), coronavirus (328), and parainfluenza virus (58) infections.”
From The airway epithelium: soldier in the fight against respiratory viruses (2011) · cites this paper as [21]
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“For instance, echocardiography shows a precision error of around 30% when compared to gold standard dilution techniques, which falls within the clinically accepted range [54,55].”
- Authors
- Cecconi, M., Rhodes, A., Poloniecki, J., Della Rocca, G., & Grounds, R. M.
- Affiliations
- University of Udine (IT)
- St George's Hospital (GB)
- St George's, University of London (GB)
- Corresponding author
- Cecconi, Maurizio
- Venue
- Critical Care
- Published
- 2009
- Volume
- 13
- Issue
- 1
- Pages
- 201
- ISSN
- 1364-8535 (ISSN-L)
- PMC
- PMC2688094
- OpenAlex
- W2155688319
- Cited by
- 351
- References
- 24
- Citations by year
- 2026: 16 · 2025: 16 · 2024: 18 · 2023: 20 · 2022: 15 · 2021: 24 · 2020: 17 · 2019: 20 · 2018: 18 · 2017: 23 · 2016: 29 · 2015: 42 · 2014: 24 · 2013: 20 · 2012: 15
- FWCI
- 16.56
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Locations
- Critical Care (publishedVersion)
- Europe PMC (PubMed Central) (publishedVersion)
- PubMed Central (publishedVersion)
- PubMed (publishedVersion)
- St George's Online Research Archive (St George's University of London) (acceptedVersion)
- Institutional Research Information System (University of Udine) (submittedVersion)
- Topics
- Health Sciences › Medicine › Surgery › Hemodynamic Monitoring and Therapy
- Social Sciences › Decision Sciences › Statistics, Probability and Uncertainty › Reliability and Agreement in Measurement
- Health Sciences › Medicine › Physiology › Clinical Laboratory Practices and Quality Control
- Keywords
- cardiac output monitoring, method comparison, Bland-Altman analysis, measurement agreement, percentage error, limits of agreement, bias
- MeSH terms
- Cardiac Output, Humans, Monitoring, Physiologic, Reference Standards, Reproducibility of Results, Point-of-Care Systems, Biomedical Research
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