Fröhlich Daniela, Bittersohl Christin, Schroeder Katrin, Schöttle Daniel, Kowalinski Eva, Borgwardt Stefan, Lang Undine E, Huber Christian G
Universitäre Psychiatrische Kliniken Basel, Universität Basel, Basel, Switzerland.
Klinik und Poliklinik für Psychiatrie und Psychotherapie, Universitätsklinik Hamburg-Eppendorf, Hamburg, Germany.
Front Psychiatry. 2020 Jan 14;10:954. doi: 10.3389/fpsyt.2019.00954. eCollection 2019.
Health services research is of increasing importance in current psychiatry. Therefore, large datasets and aggregation of data generated by electronic routine documentation due to legal, financial, or administrative purposes play an important role. However, paper-based routine documentation is still of interest. It remains relevant in less developed health care systems, in emergency settings, and in long-term retrospective and historical studies. Whereas studies examining the reliability of electronic routine documentation support the application of routine data for research purposes, our knowledge regarding reliability of paper-based routine documentation is still very sparse. Basic documentation (BADO) was completed on paper forms and digitalized manually for all inpatients of the Department of Psychiatry and Psychotherapy, University Hospital Hamburg-Eppendorf, Germany, treated within the time period from 1998 to 2006. Four hundred twelve cases of first-episode psychosis patients were chosen for comparison with clinical data from paper-based patient files. The percentage of missing information, the percentage of correct classifications, sensitivity, and positive predictive value were calculated for all applicable variables. In eight cases (1.9%), a BADO form was available, but was not filled in. In 37 cases (7.0%), the patient files were lost and could not be obtained from the centralized archive. Routine data were available for all other cases in 20 (58.8%) of the examined 34 variables, and the percentage of missing data for the remaining variables ranged between 0.3% and 22.9%, with only the variables education and suicidality during treatment having more than 5% missing data. In general, the overall rate of correct classifications was high, with a median percentage of 86.4% to 99.7% for the examined variables. Sensitivity was above 75% for eight and <75% but above 50% for six of the examined 17 variables. Values for the positive predictive value were above 75% for nine and <75% but above 50% for three variables. In summary, paper-based routine documentation reaches acceptable reliability, but this is dependent on the chosen documentation categories and variables. Based on the present findings, paper-based routine documentation can indeed be used for quality management, organizational development, and health services research. Its limitations, however, have to be kept in mind.
卫生服务研究在当前精神病学领域的重要性日益凸显。因此，出于法律、财务或行政目的，通过电子常规记录生成的大型数据集和数据汇总发挥着重要作用。然而，纸质常规记录仍具有研究价值。在欠发达的医疗系统、紧急情况以及长期回顾性和历史性研究中，它依然具有相关性。尽管有关电子常规记录可靠性的研究支持将常规数据用于研究目的，但我们对纸质常规记录可靠性的了解仍然非常有限。德国汉堡 - 埃彭多夫大学医院精神病学与心理治疗科在1998年至2006年期间收治的所有住院患者的基本记录（BADO）采用纸质表格填写，并进行手动数字化处理。选取了412例首发精神病患者的病例，与纸质患者档案中的临床数据进行比较。针对所有适用变量计算了缺失信息的百分比、正确分类的百分比、敏感度和阳性预测值。有8例（1.9%）存在BADO表格，但未填写。37例（7.0%）患者档案丢失，无法从中央档案库获取。在所检查的34个变量中，20个（58.8%）变量的常规数据对所有其他病例均可用，其余变量的缺失数据百分比在0.3%至22.9%之间，只有“教育程度”和“治疗期间自杀倾向”这两个变量的缺失数据超过5%。总体而言，正确分类的总体率较高，所检查变量的中位数百分比在86.4%至99.7%之间。在17个所检查变量中，8个变量的敏感度高于75%，6个变量的敏感度低于75%但高于50%。9个变量的阳性预测值高于75%，3个变量的阳性预测值低于75%但高于50%。总之，纸质常规记录具有可接受的可靠性，但这取决于所选的记录类别和变量。基于目前的研究结果，纸质常规记录确实可用于质量管理、组织发展和卫生服务研究。然而，必须牢记其局限性。
