Assessment of asthma using automated and full-text medical records
Assessment of asthma using automated and full-text medical records
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DOI：
10.3109/02770909709067217
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发表时间：
1997-01-01
影响因子：
1.9
通讯作者：
Platt, R
中科院分区：
文献类型：
--
作者：
Donahue, JG;Weiss, ST;Platt, R
自动化医疗记录系统用于研究临床结果和护理质量，但这需要准确的疾病识别和严重程度评估。我们试图确定通过自动医疗和药房记录识别哮喘患者的可靠性，以及这些数据用于严重程度评估的充分性。确定了1988年4月至1991年9月期间接受至少一种哮喘药物和哮喘诊断的所有成人健康维护组织（HMO）成员。随机抽样的记录进行了审查，以验证诊断和提取临床信息。向15，491人分发了哮喘药物; 7583人（49%）也接受了哮喘诊断。与未确诊的人相比，确诊哮喘的人使用哮喘药物的比例高出三倍。记录回顾显示，编码哮喘诊断的阳性预测值为86%。近4000门诊就诊进行了审查，其中10%是哮喘;中位数的遭遇是两个。9%的患者提到了哮喘症状，喘息是最常见的。分别在4%和1%的遭遇中测量了峰值流量和肺活量。接受哮喘药物治疗的哮喘患者的记录显示，79%的人没有哮喘。来自HMO的自动医疗和药房记录在用于识别哮喘患者时相对准确。同样，大多数哮喘药物接受者缺乏哮喘的编码诊断，没有哮喘。然而，传统的全文记录通常不包含足够的信息来评估哮喘的严重程度，限制了这些记录在研究和质量改进中的实用性。
Automated medical records systems are used to study clinical outcomes and quality of care, but this requires accurate disease identification and assessment of severity. We sought to determine the reliability of identifying asthmatics through automated medical and pharmacy records, and the adequacy of such data for severity assessment. All adult health maintenance organization (HMO) members who received at least one asthma drug and an asthma diagnosis between April 1988 and September 1991 were identified. Records of a random sam pie were reviewed to validate the diagnosis and extract clinical information. Asthma drugs were dispensed to 15,491 individuals; 7583 (49%) also received an asthma diagnosis. Asthma drug use was three times greater for persons with diagnosed asthma compared to those with no diagnosis. Record review revealed that a coded asthma diagnosis had a positive predictive value of 86%. Nearly 4000 ambulatory encounters were reviewed, 10% of which were for asthma; the median number of encounters was two. Asthma symptoms were mentioned in 9% of all encounters; wheezing was most common. Peak flow and spirometry were measured in 4% and 1% of encounters, respectively. Records from recipients of asthma drugs who racked an asthma diagnosis showed that 79% did not have asthma. Automated medical and pharmacy records from an HMO were relatively accurate when used to identify individuals with asthma. Similarly, most asthma drug recipients who lacked a coded diagnosis of asthma did not have asthma. However, convention al full-text records usually do not con ta in sufficient information to assess asthma severity, limiting the utility of such records for research and quality improvement.