Profiling quality of care: Is there a role for peer review?
Profiling quality of care: Is there a role for peer review?
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DOI：
10.1186/1472-6963-4-9
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发表时间：
2004-05-19
影响因子：
2.8
通讯作者：
Kerr EA
中科院分区：
文献类型：
--
作者：
Hofer TP;Asch SM;Hayward RA;Rubenstein LV;Hogan MM;Adams J;Kerr EA
我们试图开发一种更可靠的结构化隐式图表审查工具，用于评估慢性病的护理质量，并检查评级是否更可靠的条件下，实践的证据基础更加发达。我们在一个队列中进行了可靠性研究，患者记录包括门诊和住院护理作为测量对象。我们开发了一个结构化的隐性审查工具，以评估一年的治疗护理质量。12名评审员对从该国两个地区的26个VA临床研究中心选择的70份患者记录进行了总计496次评审。每名患者有1至4种疾病，被指定为具有高度发达的证据基础（糖尿病和高血压）或不太发达的证据基础（慢性阻塞性肺病或急性疾病的集合）。多层次分析，占嵌套和交叉分类的数据结构被用来估计信号和噪声分量的测量质量和可靠性的隐式审查。对于COPD和急性疾病的集合，单个医生审查的可靠性相当低（类内相关性= 0.16-0.26），但与大多数先前发表的在住院环境中使用该方法的估计值相当。然而，对于糖尿病和高血压，可靠性显著更高，为0.46。较高的可靠性是由于评审员能够共同区分患者之间护理质量的更多差异（p < 0.007），而不是由于测量中较少的随机噪声或个体评审员偏倚。对于这些情况，患者的真实质量水平（即，由全部医生评审员评审记录所产生的护理质量评级）从差到好不等。对于具有完善的护理质量证据基础的疾病，如高血压和糖尿病，评估一段时间内护理质量的单一结构化隐式审查是中等可靠的。这种方法可能是一个合理的补充或替代明确的指标方法评估和比较护理质量。结构化的隐性审查，如明确的质量措施，必须更谨慎地用于证据基础不太完善的疾病，如COPD和急性，短期疾病。
We sought to develop a more reliable structured implicit chart review instrument for use in assessing the quality of care for chronic disease and to examine if ratings are more reliable for conditions in which the evidence base for practice is more developed. We conducted a reliability study in a cohort with patient records including both outpatient and inpatient care as the objects of measurement. We developed a structured implicit review instrument to assess the quality of care over one year of treatment. 12 reviewers conducted a total of 496 reviews of 70 patient records selected from 26 VA clinical sites in two regions of the country. Each patient had between one and four conditions specified as having a highly developed evidence base (diabetes and hypertension) or a less developed evidence base (chronic obstructive pulmonary disease or a collection of acute conditions). Multilevel analysis that accounts for the nested and cross-classified structure of the data was used to estimate the signal and noise components of the measurement of quality and the reliability of implicit review. For COPD and a collection of acute conditions the reliability of a single physician review was quite low (intra-class correlation = 0.16–0.26) but comparable to most previously published estimates for the use of this method in inpatient settings. However, for diabetes and hypertension the reliability is significantly higher at 0.46. The higher reliability is a result of the reviewers collectively being able to distinguish more differences in the quality of care between patients (p < 0.007) and not due to less random noise or individual reviewer bias in the measurement. For these conditions the level of true quality (i.e. the rating of quality of care that would result from the full population of physician reviewers reviewing a record) varied from poor to good across patients. For conditions with a well-developed quality of care evidence base, such as hypertension and diabetes, a single structured implicit review to assess the quality of care over a period of time is moderately reliable. This method could be a reasonable complement or alternative to explicit indicator approaches for assessing and comparing quality of care. Structured implicit review, like explicit quality measures, must be used more cautiously for illnesses for which the evidence base is less well developed, such as COPD and acute, short-course illnesses.
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影响因子：
120.7
作者：
Hayward, RA;Hofer, TP
通讯作者：
Hofer, TP
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120.7
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作者：
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