Warsi A A, White S, McCulloch P
University Hospital Aintree, Liverpool, UK.
Eur J Surg Oncol. 2002 Dec;28(8):850-6. doi: 10.1053/ejso.2002.1283.
Clinical databases are regularly used for audit and research purposes. The accuracy of data input is critical to the value of these tools, but little is known about the factors which influence the completeness of data recording. The aim of this study was to evaluate the influences affecting completeness of data recording in computerized clinical databases of cancer treatment.
Data omission rates in three databases dealing with management of breast, colorectal and gastro-oesophageal cancers were calculated. The effects of (a) type of record; (b) nature of data and (c) training required to interpret data were evaluated by univariate and multivariate analyses.
The overall data omission rate was 21.9% (upper GI 27.6%, breast 19.6%, colorectal 32.7%, P=0.13). For different categories of data, omission rates varied from 0% to 55%. Fields requiring a 'text field' or 'numerical' entry, or containing demographic data, data required for the process of care or data which required no interpretation were associated with low omission rates. Clinical data, and fields requiring a 'yes/no' response were associated with high omission rates (45 and 48% respectively). Clinical data and data relating to patient demographic details were independently associated with high and low omission rates respectively (odds ratios for significant missing data 86.9 and 1 respectively).
Clinical data are poorly captured by current cancer surgery databases. Reasons for the poor completion of fields requiring input by clinical staff, particularly availability of time and training, and prioritization of work, should be addressed. Re-design of databases to ensure that data entry is simple and unambiguous may improve accuracy.
临床数据库常用于审核和研究目的。数据输入的准确性对于这些工具的价值至关重要，但对于影响数据记录完整性的因素却知之甚少。本研究的目的是评估影响癌症治疗计算机化临床数据库中数据记录完整性的因素。
计算了三个处理乳腺癌、结直肠癌和胃食管癌管理的数据库中的数据遗漏率。通过单因素和多因素分析评估了（a）记录类型；（b）数据性质；（c）解释数据所需培训的影响。
总体数据遗漏率为21.9%（上消化道27.6%，乳腺19.6%，结直肠32.7%，P = 0.13）。对于不同类别的数据，遗漏率从0%到55%不等。需要“文本字段”或“数字”输入、包含人口统计学数据、护理过程所需数据或无需解释的数据的字段，其遗漏率较低。临床数据以及需要“是/否”回答的字段，其遗漏率较高（分别为45%和48%）。临床数据和与患者人口统计学细节相关的数据分别与高遗漏率和低遗漏率独立相关（显著缺失数据的优势比分别为86.9和1）。
当前的癌症手术数据库对临床数据的采集较差。应解决临床工作人员输入字段填写不完整的原因，特别是时间和培训的可用性以及工作优先级。重新设计数据库以确保数据输入简单明了，可能会提高准确性。
