Gallai Virgilio, Sarchielli Paola, Alberti Andrea, Pedini Mauro, Gallai Beatrice, Rossi Cristiana, Cittadini Elisabetta
The Neuroscience Department, University of Perugia, Italy.
Headache. 2002 Nov-Dec;42(10):1016-24. doi: 10.1046/j.1526-4610.2002.02231.x.
The actual application of the current International Headache Society (IHS) diagnostic criteria in clinical practice has not been investigated thoroughly.
To develop a computerized, structured, medical record based exclusively on the IHS classification system.
We tested the computerized structured record by entering and analyzing data reported on the case sheets of 500 consecutive patients attending nine headache centers in Italy. All clinical diagnoses in the study were made according to current IHS criteria. The rate of concordance between the diagnosis provided by the computerized structured record and that reported by clinicians on the case sheets was calculated, and reasons for any discrepancies between the two diagnoses were analyzed.
Concordance between the two diagnoses was found in 345 of 500 cases examined (69%). In the remaining 155 cases, diagnoses reached with the computerized structured record and case sheets were impossible or discordant with respect to the diagnoses made by the clinician. In 144 of these cases (28.8%), this was due to missing information or errors in the diagnosis recorded by the clinicians on the patient case sheet. In particular, the diagnosis could not be reached using the computerized structured record in 105 cases (20.6%) because of a lack of one or more data needed in formulating a correct diagnosis according to the IHS operational criteria for one of the primary headache disorders. In the remaining 41 cases some data were missing, but the data available were sufficient to reach a diagnosis according to the IHS criteria. Moreover, the diagnoses reached using the computerized structured record were not in agreement with those made by the clinicians in another 39 cases (7.9%) due to an incorrect interpretation by the clinicians of the data reported on the patients' case sheets. In only 2.2% of the cases (n = 11) misdiagnoses were due to errors of the program that were promptly corrected.
The present study suggests that incorrect application of IHS criteria for the diagnosis of primary headache may occur in as many as one third of patients attending headache centers and that use of a computerized structured record based exclusively on current IHS criteria may overcome this deficiency.
目前国际头痛协会（IHS）诊断标准在临床实践中的实际应用尚未得到充分研究。
开发一种完全基于IHS分类系统的计算机化、结构化的病历。
我们通过录入和分析意大利九个头痛中心连续500例患者病历表上报告的数据，对计算机化结构化病历进行了测试。研究中的所有临床诊断均根据当前IHS标准做出。计算计算机化结构化病历提供的诊断与临床医生在病历表上报告的诊断之间的一致性率，并分析两种诊断之间存在差异的原因。
在500例检查病例中，有345例（69%）两种诊断结果一致。在其余155例中，计算机化结构化病历和病历表得出的诊断与临床医生做出的诊断不一致或无法得出诊断。在其中144例（28.8%）中，这是由于临床医生在患者病历表上记录的信息缺失或诊断错误。特别是，在105例（20.6%）病例中，由于缺乏根据IHS原发性头痛疾病操作标准做出正确诊断所需的一项或多项数据，无法使用计算机化结构化病历得出诊断。在其余41例中，一些数据缺失，但可用数据足以根据IHS标准得出诊断。此外，在另外39例（7.9%）病例中，由于临床医生对患者病历表上报告的数据解释错误，使用计算机化结构化病历得出的诊断与临床医生做出的诊断不一致。仅在2.2%的病例（n = 11）中，误诊是由于程序错误，这些错误已迅速得到纠正。
本研究表明，在前往头痛中心就诊的患者中，多达三分之一的患者可能存在IHS标准在原发性头痛诊断中的应用错误，而使用完全基于当前IHS标准的计算机化结构化病历可能会克服这一缺陷。
