Lubrano E, Butterworth M, Hesselden A, Wells S, Helliwell P
Rheumatology and Rehabilitation Research Unit, University of Leeds, UK.
Clin Rehabil. 1998 Jun;12(3):216-20. doi: 10.1191/026921598675367725.
The main treatments for ankylosing spondylitis (AS) are physical (exercise and stretching), and one way of measuring the effectiveness of these therapies is to record spinal movements in a standardized way. Patients are often seen in both medical (rheumatology) and physiotherapy clinics where duplicate information on their progress may be obtained. The purpose of this study was to assess the completeness of data collection for patients attending both medical and physiotherapy clinics.
An audit of data recorded in medical and physiotherapy notes.
Patient records identified either from computerized databases (Huddersfield and Bradford) or from a clinic at which only AS patients attended (Leeds). Data from attendances over a defined period were retrieved and recorded on a standard form. All patients thus identified were then cross-matched against those patients attending for physiotherapy during the same period and, where a match occurred, the same data were retrieved from the physiotherapy notes. MINIMUM DATA SET FOR AUDIT: Before data collection started all participants agreed on the minimum data set required for adequate monitoring of patients with AS. The anthropometric measurements included height, chest expansion, cervical rotation, tragus to wall, modified Schober's flexion, extension, lumbar side flexion, intermalleolar abduction, and interfingertip abduction.
Of 182 medical notes screened, 46 patients had not been seen in the defined period, leaving 136 notes to be reviewed. Of these, 52 patients had been seen in physiotherapy in the same period. In general, measurements were infrequently found in medical notes (only chest expansion in 58%, Schober's flexion in 48% and tragus to wall in 47% were measured with any regularity by medical staff). In contrast, corresponding data from physiotherapy notes were more complete (Schober's flexion and lumbar side flexion in 96%, height in 87%, intermalleolar distance in 87% and cervical rotation in 83%).
Follow-up and monitoring of AS patients in these medical clinics is clearly inadequate. Physiotherapy-led clinics have already been started in one of the study hospitals and the other centres are reviewing their arrangements for AS follow-up, including the possibility of a combined approach to patient management.
强直性脊柱炎（AS）的主要治疗方法是物理治疗（运动和伸展），衡量这些疗法有效性的一种方法是以标准化方式记录脊柱活动。患者常就诊于内科（风湿病科）和物理治疗诊所，可能会获取有关其病情进展的重复信息。本研究的目的是评估同时就诊于内科和物理治疗诊所的患者数据收集的完整性。
对内科和物理治疗记录中的数据进行审核。
从计算机数据库（哈德斯菲尔德和布拉德福德）或仅收治AS患者的诊所（利兹）中识别出的患者记录。检索并记录在规定时间段内就诊的数据，并填写在标准表格上。然后将所有识别出的患者与同期接受物理治疗的患者进行交叉匹配，若有匹配，则从物理治疗记录中检索相同数据。审核的最小数据集：在数据收集开始前，所有参与者就充分监测AS患者所需的最小数据集达成一致。人体测量指标包括身高、胸廓扩张度、颈椎旋转度、耳屏至墙壁距离、改良Schober试验的前屈、后伸、腰椎侧屈、内踝间距和指尖间距。
在筛查的182份内科记录中，46例患者在规定时间段内未就诊，剩余136份记录有待审核。其中，52例患者同期接受了物理治疗。总体而言，内科记录中测量指标较少见（医护人员定期测量的指标中，仅胸廓扩张度为58%，Schober试验前屈为48%，耳屏至墙壁距离为47%）。相比之下，物理治疗记录中的相应数据更完整（Schober试验前屈和腰椎侧屈为96%，身高为87%，内踝间距为87%，颈椎旋转度为83%）。
这些内科诊所对AS患者的随访和监测明显不足。其中一家研究医院已开设了以物理治疗为主导的诊所，其他中心也在审查其AS随访安排，包括采用联合方式管理患者的可能性。
