Peabody John W, Luck Jeff, Glassman Peter, Jain Sharad, Hansen Joyce, Spell Maureen, Lee Martin
San Francisco Veterans Affairs Medical Center, Institute for Global Health, University of California, San Francisco 94105, USA.
Ann Intern Med. 2004 Nov 16;141(10):771-80. doi: 10.7326/0003-4819-141-10-200411160-00008.
Worldwide efforts are under way to improve the quality of clinical practice. Most quality measurements, however, are poorly validated, expensive, and difficult to compare among sites.
To validate whether vignettes accurately measure the quality of clinical practice by using a comparison with standardized patients (the gold standard method), and to determine whether vignettes are a more or less accurate method than medical record abstraction.
Prospective, multisite study.
Outpatient primary care clinics in 2 Veterans Affairs medical centers and 2 large, private medical centers.
144 of 163 eligible physicians agreed to participate, and, of these, 116 were randomly selected to see standardized patients, to complete vignettes, or both.
Scores, expressed as the percentage of explicit quality criteria correctly completed, were obtained by using 3 methods.
Among all physicians, the quality of clinical practice as measured by the standardized patients was 73% correct (95% CI, 72.1% to 73.4%). By using exactly the same criteria, physicians scored 68% (CI, 67.9% to 68.9%) when measured by the vignettes but only 63% (CI, 62.7% to 64.0%) when assessed by medical record abstraction. These findings were consistent across all diseases and were independent of case complexity or physician training level. Vignettes also accurately measured unnecessary care. Finally, vignettes seem to capture the range in the quality of clinical practice among physicians within a site.
Despite finding variation in the quality of clinical practice, we did not determine whether poorer quality translated into worse health status for patients. In addition, the quality scores are based on measurements from 1 patient-provider interaction. As with all other scoring criteria, vignette criteria must be regularly updated.
Vignettes are a valid tool for measuring the quality of clinical practice. They can be used for diverse clinical settings, diseases, physician types, and situations in which case-mix variation is a concern. They are inexpensive and easy to use. Vignettes are particularly useful for comparing quality among and within sites and may be useful for longitudinal evaluations of interventions intended to change clinical practice.
全球都在努力提高临床实践质量。然而，大多数质量衡量方法的验证程度较低、成本高昂且各机构之间难以比较。
通过与标准化患者（金标准方法）进行比较，验证病例 vignettes 是否能准确衡量临床实践质量，并确定 vignettes 相较于病历摘要是否是一种更准确或更不准确的方法。
前瞻性多中心研究。
2 家退伍军人事务医疗中心和 2 家大型私立医疗中心的门诊初级保健诊所。
163 名符合条件的医生中有 144 名同意参与，其中 116 名被随机选择去看标准化患者、完成病例 vignettes 或两者皆做。
通过 3 种方法获得得分，以正确完成的明确质量标准的百分比表示。
在所有医生中，标准化患者衡量的临床实践质量正确率为 73%（95%置信区间，72.1%至 73.4%）。使用完全相同的标准，通过病例 vignettes 测量时医生得分为 68%（置信区间，67.9%至 68.9%），而通过病历摘要评估时仅为 63%（置信区间，62.7%至 64.0%）。这些结果在所有疾病中都一致，且与病例复杂性或医生培训水平无关。病例 vignettes 也能准确衡量不必要的医疗。最后，病例 vignettes 似乎能反映一个机构内医生临床实践质量的范围。
尽管发现了临床实践质量存在差异，但我们并未确定质量较差是否会转化为患者更差的健康状况。此外，质量得分基于 1 次患者 - 提供者互动的测量。与所有其他评分标准一样，病例 vignettes 标准必须定期更新。
病例 vignettes 是衡量临床实践质量的有效工具。它们可用于各种临床环境、疾病、医生类型以及关注病例组合差异的情况。它们成本低廉且易于使用。病例 vignettes 对于比较不同机构之间以及机构内部的质量特别有用，并且可能对旨在改变临床实践的干预措施的纵向评估有用。
