Alves Elisabete, Lunet Nuno, Correia Sofia, Morais Vítor, Azevedo Ana, Barros Henrique
Department of Hygiene and Epidemiology, University of Porto Medical School, Porto, Portugal.
Gac Sanit. 2011 May-Jun;25(3):211-9. doi: 10.1016/j.gaceta.2010.10.013. Epub 2011 Apr 3.
To assess the yield of medical record review to recover missing data originally collected by questionnaire, to analyze the agreement between these two data sources and to determine interobserver variability in clinical record review.
We analyzed data from a birth cohort of 8,127 women who were consecutively recruited after giving birth from 2005-2006. Recruitment was conducted at all public maternity units of Porto, Portugal. We reviewed the medical records of 3,657 women with missing data in the baseline questionnaire and assessed agreement between these two sources by using information from participants with data from both sources. Interobserver variability was assessed by using 400 randomly selected clinical records.
Data on pregnancy complications and maternal anthropometric parameters were successfully recovered. Agreement between the questionnaire and records in family history data was fair, particularly for cardiovascular disease [k=0.27; 95% confidence interval (95%CI): 0.23-0.32]. The highest agreement was observed for personal history of diabetes (k=0.82; 95%CI 0.70-0.93), while agreement for hypertension was moderate (k=0.60; 95%CI 0.50-0.69). Discrepancies in prepregnancy body mass index classes were observed in 10.3% women. Data were highly consistent between the two reviewers, with the highest agreement found for gestational diabetes (k=1.00) and birth weight (99.5% concordance).
Data from the medical records and questionnaire were concordant with regard to pregnancy and well-known risk factors. The low interobserver variability did not threaten the precision of our data.
评估病历审查以找回最初通过问卷收集的缺失数据的效果,分析这两个数据源之间的一致性,并确定临床病历审查中的观察者间变异性。
我们分析了2005年至2006年分娩后连续招募的8127名女性的出生队列数据。招募在葡萄牙波尔图的所有公立产科单位进行。我们审查了基线问卷中有缺失数据的3657名女性的病历,并通过使用来自两个数据源都有数据的参与者的信息来评估这两个数据源之间的一致性。通过使用400份随机选择的临床病历评估观察者间变异性。
成功找回了妊娠并发症和产妇人体测量参数的数据。问卷和病历在家族史数据方面的一致性一般,特别是对于心血管疾病[k = 0.27;95%置信区间(95%CI):0.23 - 0.32]。糖尿病个人史的一致性最高(k = 0.82;95%CI 0.70 - 0.93),而高血压的一致性中等(k = 0.60;95%CI 0.50 - 0.69)。10.3%的女性在孕前体重指数类别上存在差异。两位审查者之间的数据高度一致,妊娠糖尿病(k = 1.00)和出生体重(一致性为99.5%)的一致性最高。
病历和问卷的数据在妊娠和知名风险因素方面是一致的。低观察者间变异性并未威胁到我们数据的准确性。