Robertson Douglas J, Lawrence Laura B, Shaheen Nicholas J, Baron John A, Paskett Electra, Petrelli Nicholas J, Sandler Robert S
Dartmouth Medical School, Section of Biostatistics and Epidemiology, Lebanon, New Hampshire, USA.
Am J Gastroenterol. 2002 Oct;97(10):2651-6. doi: 10.1111/j.1572-0241.2002.06044.x.
Several groups have developed guidelines for specific content necessary in endoscopic procedure reports. Little information is available assessing adherence to reporting recommendations, and little is known about common reporting errors. The aim of this study was to assess the quality of colonoscopy reporting and to identify possible areas of improvement.
Using the 1997 American Society for GI Endoscopy guidelines for endoscopy reporting, we created operational definitions for adherence to each guideline. We then created 31 specific process of care criteria to assess adherence to each of these operational definitions. We subdivided the 31 specific process of care criteria into six domains: demographic information, patient history, sedation procedure, adequacy of preparation/visibility, lesion identification/removal, and procedure interpretation. Reports obtained from 122 separate endoscopy centers were reviewed for adherence to the guidelines. Adequate performance for any criterion was defined as 70% or better compliance.
Performance varied widely across the domains. Clinicians demonstrated adequate performance on sedation procedure (75%) and lesion identification/removal (84%). Clinicians scored poorly on demographic data (69%), patient history (57%), procedure quality (40%), and procedure interpretation (58%).
Clinicians' colonoscopy reporting practices are widely variable and often suboptimal. There is an opportunity to improve the quality of care in colonoscopy reporting by improving physicians' adherence to established standards.
多个小组已制定了内镜检查报告所需特定内容的指南。但评估对报告建议的遵循情况的信息很少，且对常见报告错误了解甚少。本研究的目的是评估结肠镜检查报告的质量，并确定可能的改进领域。
我们依据1997年美国胃肠内镜学会的内镜检查报告指南，为每条指南的遵循情况制定了操作定义。然后，我们创建了31条具体的护理流程标准，以评估对这些操作定义的遵循情况。我们将这31条具体的护理流程标准细分为六个领域：人口统计学信息、患者病史、镇静程序、准备/视野的充分性、病变识别/切除以及程序解读。对从122个独立内镜检查中心获取的报告进行审查，以评估其对指南的遵循情况。任何标准的充分表现定义为依从率达到70%或更高。
各领域的表现差异很大。临床医生在镇静程序（75%）和病变识别/切除（84%）方面表现充分。临床医生在人口统计学数据（69%）、患者病史（57%）、程序质量（40%）和程序解读（58%）方面得分较低。
临床医生的结肠镜检查报告做法差异很大，且往往不够理想。通过提高医生对既定标准的遵循程度，有机会改善结肠镜检查报告中的护理质量。
