Hannan E L, Bernard H R, O'Donnell J F, Kilburn H
Bureau of Health Care Research and Information Services, New York State Department of Health, Albany 12237.
Am J Public Health. 1989 Apr;79(4):430-6. doi: 10.2105/ajph.79.4.430.
We tested the efficacy of selected case characteristics in targeting quality of care problems for medical record review. The case characteristics, all of which apply to patients who die in a hospital, consist primarily of procedures and DRGs (diagnosis-related groups) for which death rarely occurs, and a set of complications of surgical care. All characteristics are obtainable from combinations of the principal and secondary diagnoses and procedures in the case, and are available from discharge abstracts. The presence of a quality of care problem is confirmed through a review of the medical record by a nurse and two or more physicians. A logistic regression model that controls for various patient and hospital variables is used as a measure of each of the proposed case characteristics. The results indicate that most of the characteristics are associated with higher percentages of quality of care problems than cases chosen at random, and that the methodology has promise as a tool for targeting cases for medical record review.
我们测试了选定病例特征在针对医疗记录审查中的护理质量问题方面的有效性。这些病例特征主要包括死亡极少发生的手术和诊断相关分组（DRG），以及一组手术护理并发症，所有这些特征均适用于在医院死亡的患者。所有特征均可从病例中的主要和次要诊断及手术的组合中获取，并且可从出院摘要中获得。护理质量问题的存在通过一名护士和两名或更多医生对医疗记录的审查得以确认。使用一个控制各种患者和医院变量的逻辑回归模型来衡量每个提议的病例特征。结果表明，与随机选择的病例相比，大多数特征与更高比例的护理质量问题相关，并且该方法有望作为一种针对医疗记录审查病例的工具。
