Mayfield J A, Rith-Najarian S J, Acton K J, Schraer C D, Stahn R M, Johnson M H, Gohdes D
Department of Family Medicine, Bowen Research Center, Indiana University, Indianapolis 46202.
Diabetes Care. 1994 Aug;17(8):918-23. doi: 10.2337/diacare.17.8.918.
To evaluate the adherence to minimum standards for diabetes care in multiple primary-care facilities using a uniform system of medical record review.
In 1986, the Indian Health Service (IHS) developed diabetes care standards and an assessment process to evaluate adherence to those standards using medical record review. We review our assessment method and results for 1992. Charts were selected in a systematic random fashion from 138 participating facilities. Trained professional staff reviewed patient charts, using a uniform set of definitions. A weighted rate of adherence was constructed for each item.
Medical record reviews were conducted on 6,959 charts selected from 40,118 diabetic patients. High rates of adherence (> 70%) were noted for blood pressure and weight measurements at each visit, blood sugar determinations at each visit, annual laboratory screening tests, electrocardiogram at baseline, and adult immunizations. Lower rates of adherence (< or = 50%) were noted for annual eye, foot, and dental examinations.
IHS rates of adherence are similar to rates obtained from medical record reviews and computerized billing data, but are less than rates obtained by provider self-report. Medical record review, using uniform definitions and inexpensive software for data entry and reports, can easily be implemented in multiple primary-care settings. Uniformity of data definition and collection facilitates the aggregation of the data and comparison over time and among facilities. This medical record review system, although labor intensive, can be easily adopted in a variety of primary-care settings for quality improvement activities, program planning, and evaluation.
使用统一的病历审查系统，评估多个初级保健机构对糖尿病护理最低标准的遵循情况。
1986年，印第安卫生服务局（IHS）制定了糖尿病护理标准以及一个评估过程，以通过病历审查来评估对这些标准的遵循情况。我们回顾了1992年的评估方法和结果。从138个参与机构中以系统随机的方式选取病历。训练有素的专业人员使用一套统一的定义来审查患者病历。为每个项目构建了一个加权遵循率。
对从40118名糖尿病患者中选取的6959份病历进行了审查。每次就诊时的血压和体重测量、每次就诊时的血糖测定、年度实验室筛查测试、基线心电图以及成人免疫接种的遵循率较高（>70%）。年度眼科、足部和牙科检查的遵循率较低（≤50%）。
IHS的遵循率与通过病历审查和计算机计费数据获得的率相似，但低于提供者自我报告获得的率。使用统一的定义以及用于数据录入和报告的廉价软件进行病历审查，可以很容易地在多个初级保健环境中实施。数据定义和收集的一致性便于数据的汇总以及随时间和机构之间的比较。这种病历审查系统虽然劳动强度大，但可以很容易地在各种初级保健环境中采用，用于质量改进活动、项目规划和评估。
