Agreement of Ocular Symptom Reporting Between Patient-Reported Outcomes and Medical Records.
Agreement of Ocular Symptom Reporting Between Patient-Reported Outcomes and Medical Records.
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DOI：
10.1001/jamaophthalmol.2016.5551
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发表时间：
2017-03-01
影响因子：
8.1
通讯作者：
Woodward MA
中科院分区：
文献类型：
--
作者：
Valikodath NG;Newman-Casey PA;Lee PP;Musch DC;Niziol LM;Woodward MA
在电子病历 (MR) 中准确记录患者症状对于高质量的患者护理非常重要。探讨患者眼部症状问卷 (ESQ) 自我报告与 MR 记录之间的不一致。观察性研究。学术机构的综合眼科和角膜诊所。对 192 名连续、符合条件的患者进行了方便抽样，其中 30 名拒绝参与。 ESQ 上报告的症状与 MR 中记录的数据的一致性。使用 kappa 系数和 McNemar 检验分析症状报告的一致性。不一致被定义为阴性症状报告或在 ESQ 上报告中度至重度症状的患者的 MR 中未提及症状。使用逻辑回归来调查患者因素、医生特征或诊断是否与视力模糊、眼睛疼痛和眼睛发红症状的不一致概率相关。纳入 162 名患者（324 只眼睛）。受试者平均年龄为 56.6 ± 19.4 岁，其中 62% 为女性，85% 为白人。在受试者层面，160 名受试者中有 54 名 (34%) 的 ESQ 和 MR 视力模糊报告不一致。同样，报告眩光（48%，n=162 中的 n=78）、眼痛（27%，162 中 n=43）和眼睛发红（25%，162 中 n=40）的记录不一致，一致性较差到一般（kappa 范围 = -0.02-0.42）。症状报告不一致的更常见特征是 ESQ 的积极报告和 MR 中缺乏记录（Holm 调整后的 McNemar p <0.03，对于八种症状中的 7 种，除了视力模糊之外，p=0.59）。与新就诊相比，患者在 ESQ 上报告视力模糊的回访增加了在 MR 中未报告症状的可能性（Holm 调整后的 p=0.045）。患者在 ESQ 上的自我报告与 MR 中的记录之间的症状报告不一致，症状更频繁地记录在问卷上。我们的结果表明，基于 MR 数据的症状记录可能无法为临床实践或“大数据”研究提供全面的资源。
Accurate documentation of patient symptoms in the electronic medical record (MR) is important for high quality patient care. To explore inconsistencies between patient self-report on an eye symptom questionnaire (ESQ) and documentation in the MR. Observational study. Comprehensive ophthalmology and cornea clinics at an academic institution. Convenience sample of 192 consecutive, eligible patients, of whom 30 declined participation. Concordance of symptoms reported on an ESQ with data recorded in the MR. Agreement of symptom report was analyzed using kappa coefficients and McNemar’s tests. Disagreement was defined as a negative symptom report or no mention of a symptom in the MR for patients who reported moderate to severe symptoms on the ESQ. Logistic regression was used to investigate if patient factors, physician characteristics, or diagnoses were associated with the probability of disagreement for symptoms of blurry vision, eye pain, and eye redness. 162 patients (324 eyes) were included. Subjects were on average 56.6 ± 19.4 years old, 62% female, and 85% Caucasian. At the subject level, 54 of 160 (34%) had discordant reporting of blurry vision between the ESQ and MR. Likewise, documentation was discordant for reporting glare (48%, n=78 of 162), eye pain (27%, n=43 of 162), and eye redness (25%, n=40 of 162) with poor to fair agreement (kappa range = −0.02–0.42). Discordance of symptom reporting was more frequently characterized by positive reporting on the ESQ and lack of documentation in the MR (Holm’s adjusted McNemar’s p <0.03, for seven of eight symptoms except blurry vision p=0.59). Return visits where the patient reported blurry vision on the ESQ had increased odds of not reporting the symptom in the MR, compared to new visits (Holm’s adjusted p=0.045). Symptom reporting was inconsistent between a patient’s self-report on an ESQ and documentation in the MR, with symptoms more frequently recorded on a questionnaire. Our results suggest that documentation of symptoms based on MR data may not provide a comprehensive resource for clinical practice or ‘big data’ research.