Hickam D H, Sox H C, Sox C H
J Chronic Dis. 1985;38(1):91-100. doi: 10.1016/0021-9681(85)90012-8.
Because of its central importance in medical diagnosis, sources of bias in the patient history must be identified. We report here a study of interobserver agreement in chest pain histories. Histories were obtained by physicians, nurse practitioners, and self-administered questionnaires. We used a discriminant rule to classify the histories as being more or less typical of angina pectoris. A sub-group of the subjects underwent coronary arteriography after the histories were obtained. In subjects with positive coronary arteriograms, physicians consistently obtained histories typical of angina pectoris more often than a self-administered questionnaire. There was no significant systematic bias when comparing physician interviews to the questionnaire among subjects with negative arteriograms nor when comparing two physicians' interviews or a nurse practitioner interview to a questionnaire. When compared to physician interviews, nurse practitioner interviews produced histories less typical of angina pectoris. We conclude that there are systematic differences between the histories obtained by physicians, nurse practitioners, and self-administered questionnaires. Questionnaires can produce biased patient histories and should be carefully validated before being used in patient care activities or health care research.
由于患者病史在医学诊断中至关重要，因此必须明确其中可能存在的偏倚来源。我们在此报告一项关于胸痛病史中观察者间一致性的研究。病史由医生、执业护士以及自行填写的问卷获取。我们运用判别规则将病史分类为更典型或不太典型的心绞痛。在获取病史后，部分受试者接受了冠状动脉造影。在冠状动脉造影呈阳性的受试者中，医生获取典型心绞痛病史的频率始终高于自行填写的问卷。在冠状动脉造影呈阴性的受试者中，将医生访谈与问卷进行比较时，以及比较两位医生的访谈或执业护士的访谈与问卷时，均未发现显著的系统偏倚。与医生访谈相比，执业护士的访谈所得到的病史中典型心绞痛的特征较少。我们得出结论，医生、执业护士以及自行填写的问卷所获取的病史之间存在系统性差异。问卷可能会产生有偏倚的患者病史，在用于患者护理活动或医疗保健研究之前，应仔细验证。
