自我报告与病历在呼吸道疾病体征和症状方面的一致性。
Agreement between self-report and medical records on signs and symptoms of respiratory illness.
作者信息
Barbara Angela M, Loeb Mark, Dolovich Lisa, Brazil Kevin, Russell Margaret
机构信息
Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada.
出版信息
Prim Care Respir J. 2012 Jun;21(2):145-52. doi: 10.4104/pcrj.2011.00098.
BACKGROUND
Information on patient symptoms can be obtained by patient self-report or medical records review. Both methods have limitations.
AIMS
To assess the agreement between self-report and documentation in the medical records of signs/symptoms of respiratory illness (fever, cough, runny nose, sore throat, headache, sinus problems, muscle aches, fatigue, earache, and chills).
METHODS
Respondents were 176 research participants in the Hutterite Influenza Prevention Study during the 2008-2009 influenza season with information about the presence or absence of signs/symptoms from both self-report and primary care medical records.
RESULTS
Compared with medical records, lower proportions of self-reported fever, sore throat, earache, cough, and sinus problems were found. Total agreements between self-report and medical report of symptoms ranged from 61% (for sore throat) to 88% (for muscle aches and earache), with kappa estimates varying from 0.05 (for chills) to 0.41 (for cough) and 0.51 (for earache). Negative agreement was considerably higher (from 68% for sore throat to 93% for muscle aches and earache) than positive agreement (from 13% for chills to 58% for earache) for each symptom except cough where positive agreement (77%) was higher than negative agreement (64%). Agreements varied by age group. We found better agreement for earache (kappa = 0.62) and lower agreements for headache, sinus problems, muscle aches, fatigue, and chills in older children (aged >5 years) and adults.
CONCLUSIONS
Agreements were variable depending on the specific symptom. Contrary to research in other patient populations which suggests that clinicians report fewer symptoms than patients, we found that the medical record captured more symptoms than selfreport. Symptom agreement and disagreement may be affected by the perspectives of the person experiencing them, the observer, the symptoms themselves, measurement error, the setting in which the symptoms were observed and recorded, and the broader community and cultural context of patients.
背景
患者症状信息可通过患者自我报告或病历审查获得。两种方法都有局限性。
目的
评估呼吸系统疾病体征/症状（发热、咳嗽、流鼻涕、喉咙痛、头痛、鼻窦问题、肌肉疼痛、疲劳、耳痛和寒战）的自我报告与病历记录之间的一致性。
方法
受访者为2008 - 2009流感季节哈特泰特人流感预防研究中的176名研究参与者，他们同时拥有自我报告和初级保健病历中关于体征/症状是否存在的信息。
结果
与病历相比，自我报告的发热、喉咙痛、耳痛、咳嗽和鼻窦问题的比例较低。症状的自我报告与医疗报告之间的总体一致性范围为61%（喉咙痛）至88%（肌肉疼痛和耳痛），kappa估计值从0.05（寒战）到0.41（咳嗽）和0.51（耳痛）不等。除咳嗽外，每种症状的阴性一致性（从喉咙痛的68%到肌肉疼痛和耳痛的93%）均显著高于阳性一致性（从寒战的13%到耳痛的58%），咳嗽的阳性一致性（77%）高于阴性一致性（64%）。一致性因年龄组而异。我们发现，年龄较大的儿童（>5岁）和成年人中耳痛的一致性较好（kappa = 0.62），而头痛、鼻窦问题、肌肉疼痛、疲劳和寒战的一致性较低。
结论
一致性因具体症状而异。与其他患者群体的研究结果相反，其他研究表明临床医生报告的症状比患者少，而我们发现病历记录的症状比自我报告的更多。症状的一致性和不一致性可能受到经历症状的人的观点、观察者、症状本身、测量误差、观察和记录症状的环境以及患者更广泛的社区和文化背景的影响。
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