van der Heijden Laura L M, Marang-van de Mheen Perla J, Thielman Louis, Stijnen Pieter, Hamming Jaap F, Fourneau Inge
Department of Vascular Surgery, University Hospitals Leuven, Leuven, Belgium.
Department Biomedical Data Sciences, Medical Decision Making, Leiden University Medical Centre, Leiden, The Netherlands.
Int J Angiol. 2023 Feb 25;33(3):148-155. doi: 10.1055/s-0043-1761280. eCollection 2024 Sep.
Routinely reported structured data from the electronic health record (EHR) are frequently used for secondary purposes. However, it is unknown how valid routinely reported data are for reuse. This study aimed to assess the validity of routinely reported Rutherford scores by clinicians as an indicator for the validity of structured data in the EHR. This observational study compared clinician-reported Rutherford scores with medical record review Rutherford scores for all visits at the vascular surgery department between April 1, 2016 and December 31, 2018. Free-text fields with clinical information for all visits were extracted for the assignment of the medical record review Rutherford score, after which the agreement with the clinician-reported Rutherford score was assessed using Fleiss' Kappa. A total of 6,633 visits were included for medical record review. Substantial agreement was shown between clinician-reported Rutherford scores and medical record review Rutherford scores for the left ( = 0.62, confidence interval [CI]: 0.60-0.63) and right leg ( = 0.62, CI: 0.60-0.64). This increased to the almost perfect agreement for left ( = 0.84, CI: 0.82-0.86) and right leg ( = 0.85, CI: 0.83-0.87), when excluding missing clinician-reported Rutherford scores. Expert's judgment was rarely required to be the deciding factor (11 out of 6,633). Substantial agreement between clinician-reported Rutherford scores and medical record review Rutherford scores was found, which could be an indicator for the validity of routinely reported data. Depending on its purpose, the secondary use of routinely collected Rutherford scores is a viable option.
电子健康记录(EHR)中常规报告的结构化数据经常被用于次要目的。然而,尚不清楚常规报告的数据用于再利用时的有效性如何。本研究旨在评估临床医生常规报告的卢瑟福评分作为EHR中结构化数据有效性指标的有效性。这项观察性研究比较了2016年4月1日至2018年12月31日期间血管外科所有就诊病例中临床医生报告的卢瑟福评分与病历审查的卢瑟福评分。提取所有就诊病例的带有临床信息的自由文本字段,用于病历审查卢瑟福评分的赋值,之后使用Fleiss' Kappa评估与临床医生报告的卢瑟福评分的一致性。共有6633次就诊病例纳入病历审查。临床医生报告的卢瑟福评分与病历审查的卢瑟福评分在左腿(κ = 0.62,置信区间[CI]:0.60 - 0.63)和右腿(κ = 0.62,CI:0.60 - 0.64)方面显示出高度一致性。当排除缺失的临床医生报告的卢瑟福评分时,左腿(κ = 0.84,CI:0.82 - 0.86)和右腿(κ = 0.85,CI:0.83 - 0.87)的一致性提高到几乎完美。很少需要专家判断作为决定因素(6633例中有11例)。发现临床医生报告的卢瑟福评分与病历审查的卢瑟福评分之间存在高度一致性,这可能是常规报告数据有效性的一个指标。根据其用途,常规收集的卢瑟福评分的二次使用是一个可行的选择。