How well does chart abstraction measure quality? A prospective comparison of standardized patients with the medical record
How well does chart abstraction measure quality? A prospective comparison of standardized patients with the medical record
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DOI：
10.1016/s0002-9343(00)00363-6
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发表时间：
2000-06-01
影响因子：
5.9
通讯作者：
Glassman, P
中科院分区：
文献类型：
--
作者：
Luck, J;Peabody, JW;Glassman, P
目的：尽管质量测量普遍依赖于图表抽象，但对其可靠性和有效性的关注仍然存在。我们通过直接与标准化患者报告的金标准进行比较，前瞻性地评估图表抽象的有效性。对象和方法：随机选择20名普通内科住院医师和两家退伍军人事务医疗中心初级保健诊所的主治医师，对患有糖尿病、慢性阻塞性肺病、冠状动脉疾病或腰痛四种常见疾病之一的演员患者（标准化患者）进行盲目评估和治疗。使用明确的质量标准提取就诊图表；标准化患者完成包含相同标准的检查表。对于每一位医生，在四种情况下的两种不同情况下（总共160次医患接触），对质量进行了测量。我们比较了图表抽象与标准化；病人报告了四个方面的遭遇：取病史，检查病人，作出诊断，并规定适当的治疗。计算图表提取的敏感性和特异性。结果：平均（+/- SD）图表抽象得分为54% +/- 9%，显著低于标准化患者检查表的平均得分68% +/- 9% （P . 1）
PURPOSE: Despite widespread reliance on chart abstraction for quality measurement, concerns persist about its reliability and validity. We prospectively evaluated the validity of chart abstraction by directly comparing it with the gold standard of reports by standardized patients.SUBJECTS AND METHODS: Twenty randomly selected general internal medicine residents and attending faculty physicians at the primary care clinics of two Veterans Affairs Medical Centers blindly evaluated and treated actor-patients (standardized patients) who had one of four common diseases: diabetes, chronic obstructive pulmonary disease, coronary artery disease, or low back pain. Charts from the visits were abstracted using explicit quality criteria; standardized patients completed a checklist containing the same criteria. For each physician, quality was measured for two different cases of the four conditions (a total of 160 physician-patient encounters). We compared chart abstraction with standardized;patient reports for four aspects of the encounter: taking the history, examining the patient, making the diagnosis, and prescribing appropriate treat-ment. The sensitivity and specificity of chart abstraction were calculated.RESULTS: The mean (+/- SD) chart abstraction score was 54% +/- 9%, substantially less than the mean score on the standardized-patient checklist of 68% +/- 9% (P