Stange K C, Zyzanski S J, Smith T F, Kelly R, Langa D M, Flocke S A, Jaén C R
Department of Family Medicine, Case Western Reserve University, Cleveland, OH 44106, USA.
Med Care. 1998 Jun;36(6):851-67. doi: 10.1097/00005650-199806000-00009.
This study was designed to determine the optimal nonobservational method of measuring the delivery of outpatient medical services.
As part of a multimethod study of the content of primary care practice, research nurses directly observed consecutive patient visits to 138 practicing family physicians. Data on services delivered were collected using a direct observation checklist, medical record review, and patient exit questionnaires. For each medical service, the sensitivity, specificity, and Kappa statistic were calculated for medical record review and patient exit questionnaires compared with direct observation. Interrater reliability among eight research nurses was calculated using the Kappa statistic for a separate sample of videotaped visits and medical records.
Visits by 4,454 patients were observed. Exit questionnaires were returned by 74% of patients. Research nurse interrater reliabilities were generally high. The specificity of both the medical record and the patient exit questionnaire was high for most services. The sensitivity of the medical record was low for measuring health habit counseling and moderate for physical examination, laboratory testing, and immunization. The patient exit questionnaire showed moderate to high sensitivity for health habit counseling and immunization and variable sensitivity for physical examination and laboratory services.
The validity of the medical record and patient questionnaire for measuring delivery of different health services varied with the service. This report can be used to choose the optimal nonobservational method of measuring the delivery of specific ambulatory medical services for research and physician profiling and to interpret existing health services research studies using these common measures.
本研究旨在确定测量门诊医疗服务提供情况的最佳非观察性方法。
作为初级保健实践内容多方法研究的一部分，研究护士直接观察了138名执业家庭医生连续的患者就诊情况。使用直接观察清单、病历审查和患者出院问卷收集有关提供服务的数据。对于每项医疗服务，计算病历审查和患者出院问卷与直接观察相比的敏感性、特异性和kappa统计量。使用kappa统计量对录像就诊和病历的单独样本计算八名研究护士之间的评分者间信度。
观察了4454名患者的就诊情况。74%的患者返回了出院问卷。研究护士的评分者间信度普遍较高。对于大多数服务，病历和患者出院问卷的特异性都很高。病历在测量健康习惯咨询方面的敏感性较低，在体格检查、实验室检查和免疫接种方面的敏感性中等。患者出院问卷在健康习惯咨询和免疫接种方面显示出中等至高敏感性，在体格检查和实验室服务方面显示出可变敏感性。
病历和患者问卷在测量不同健康服务提供情况方面的有效性因服务而异。本报告可用于选择测量特定门诊医疗服务提供情况的最佳非观察性方法，用于研究和医生概况分析，并解释使用这些常用措施的现有卫生服务研究。
