Luck J, Peabody J W, Dresselhaus T R, Lee M, Glassman P
RAND, Santa Monica, California, USA.
Am J Med. 2000 Jun 1;108(8):642-9. doi: 10.1016/s0002-9343(00)00363-6.
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.
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 treatment. The sensitivity and specificity of chart abstraction were calculated.
The mean (+/- SD) chart abstraction score was 54% +/- 9%, substantially less than the mean score on the standardized-patient checklist of 68% +/- 9% (P <0.001). This finding was similar for all four conditions and at both sites. "False positives"-chart-recorded necessary care actions not reported by the standardized patients-resulted in a specificity of only 81%. The overall sensitivity of chart abstraction for necessary care was only 70%.
Chart abstraction underestimates the quality of care for common outpatient general medical conditions when compared with standardized-patient reports. The medical record is neither sensitive nor specific. Quality measurements derived from chart abstraction may have important shortcomings, particularly as the basis for drawing policy conclusions or making management decisions.
尽管广泛依赖病历摘要进行质量评估，但对其可靠性和有效性的担忧依然存在。我们通过将病历摘要与标准化患者报告的金标准直接比较，前瞻性地评估了病历摘要的有效性。
从两个退伍军人事务医疗中心的初级保健诊所中随机挑选20名普通内科住院医师和主治医生，对患有四种常见疾病之一（糖尿病、慢性阻塞性肺疾病、冠状动脉疾病或腰痛）的演员患者（标准化患者）进行盲法评估和治疗。使用明确的质量标准提取就诊病历；标准化患者完成包含相同标准的检查表。对于每位医生，对四种疾病中的两种不同病例进行质量评估（总共160次医患诊疗）。我们在诊疗的四个方面将病历摘要与标准化患者报告进行比较：病史采集、患者检查、诊断以及开具适当治疗方案。计算病历摘要的敏感性和特异性。
病历摘要的平均（±标准差）得分是54%±9%，显著低于标准化患者检查表的平均得分68%±9%（P<0.001）。所有四种疾病以及两个地点的情况均类似。“假阳性”——病历记录的标准化患者未报告的必要护理行为——导致特异性仅为81%。病历摘要对必要护理的总体敏感性仅为70%。
与标准化患者报告相比，病历摘要低估了常见门诊普通医疗状况的护理质量。病历既不敏感也不具有特异性。源自病历摘要的质量评估可能存在重要缺陷，尤其是作为得出政策结论或做出管理决策的依据时。
