Reliability of medical record abstraction by non-physicians for orthopedic research.
Reliability of medical record abstraction by non-physicians for orthopedic research.
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DOI：
10.1186/1471-2474-14-181
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发表时间：
2013-06-09
影响因子：
2.3
通讯作者：
Katz JN
中科院分区：
文献类型：
--
作者：
Mi MY;Collins JE;Lerner V;Losina E;Katz JN
病历审查（MRR）是临床研究中最常用的研究方法之一，因为它提供了丰富的临床细节。然而，由于 MRR 涉及对病历中信息的主观解释，因此了解从 MRR 获得的数据的可重复性至关重要。此外，由于病历审查技术要求高且时间密集，因此确定未经临床培训的受过培训的研究人员是否能够可靠地提取病历非常重要。我们评估了在转诊中心接受全膝关节置换术 (TKR) 的患者样本中提取医疗记录信息的可靠性。一名整形外科医生指导两名研究协调员 (RC) 提取接受初次 TKR 的患者的住院病历和手术记录。两名 RC 和外科医生各自独立审查了 75 名患者的记录，一名 RC 审查了两次记录。使用审阅者同意的项目比例和 kappa 统计来评估一致性。外科医生与每个 RC 之间一致性的 kappa 范围为：一个 RC 为 0.59 到 1，另一个 RC 为 0.49 到 1；一个 RC 的一致性百分比范围为 82% 到 100%，另一个 RC 的一致性百分比为 70% 到 100%。同一 RC 的重复提取显示出较高的评估者内部一致性，kappa 范围为 0.66 至 1，一致性百分比范围为 97% 至 100%。两个 RC 之间的评估者间一致性中等，kappa 范围为 0.49 至 1，一致性百分比范围为 76% 至 100%。本研究中使用的 MRR 方法对于技术复杂性较低的信息提取表现出出色的可靠性，而对于技术复杂性较高的信息则表现出中等至良好的可靠性。总的来说，这些发现支持使用非外科医生从手术记录中提取手术数据。
Medical record review (MRR) is one of the most commonly used research methods in clinical studies because it provides rich clinical detail. However, because MRR involves subjective interpretation of information found in the medical record, it is critically important to understand the reproducibility of data obtained from MRR. Furthermore, because medical record review is both technically demanding and time intensive, it is important to establish whether trained research staff with no clinical training can abstract medical records reliably. We assessed the reliability of abstraction of medical record information in a sample of patients who underwent total knee replacement (TKR) at a referral center. An orthopedic surgeon instructed two research coordinators (RCs) in the abstraction of inpatient medical records and operative notes for patients undergoing primary TKR. The two RCs and the surgeon each independently reviewed 75 patients’ records and one RC reviewed the records twice. Agreement was assessed using the proportion of items on which reviewers agreed and the kappa statistic. The kappa for agreement between the surgeon and each RC ranged from 0.59 to 1 for one RC and 0.49 to 1 for the other; the percent agreement ranged from 82% to 100% for one RC and 70% to 100% for the other. The repeated abstractions by the same RC showed high intra-rater agreement, with kappas ranging from 0.66 to 1 and percent agreement ranging from 97% to 100%. Inter-rater agreement between the two RCs was moderate with kappa ranging from 0.49 to 1 and percent agreement ranging from 76% to 100%. The MRR method used in this study showed excellent reliability for abstraction of information that had low technical complexity and moderate to good reliability for information that had greater complexity. Overall, these findings support the use of non-surgeons to abstract surgical data from operative notes.
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影响因子：
7.2
作者：
Gow, Robert M.;Barrowman, Nicholas J.;Moher, David
通讯作者：
Moher, David
影响因子：
6.2
作者：
Gilbert, EH;Lowenstein, SR;Steiner, J
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Steiner, J
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作者：
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通讯作者：
Reade, T
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作者：
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通讯作者：
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影响因子：
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作者：
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通讯作者：
KRAEMER, HC