Reliability associated with the abstraction of data from medical records for inclusion in an information system for persons with a traumatic brain injury

Labelle, Josée; Swaine, Bonnie

doi:10.1080/02699050110119880

Cited by 9 publications

(7 citation statements)

References 34 publications

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“…However, researchers can measure and report the degree to which the results obtained from data abstraction by one observation were reproduced on subsequent observations of the same record: that is, what, if any, differences were found when the data abstraction was repeated either by the same abstractor (intraobserver reliability) or by a different abstractor (interobserver reliability). 13,14,16,23 In their study of published emergency medicine MRRs, Gilbert et al reported that only 5% of 244 studies mentioned the interrater reliability and only 0.2% tested the chance-corrected interrater agreement. 12 Reporting the interrater reliability as a concordance rate or percent agreement between the observers is misleading when used alone because this indicates only whether the two observers had similar findings on similar numbers of records.…”

Section: Determining and Reporting Reliabilitymentioning

confidence: 99%

Advanced statistics: Understanding Medical Record Review (MRR) Studies

Worster

Haines

2004

Academic Emergency Medicine

195

151

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Medical record review (MRR) studies have been reported to make up 25% of all scientific studies published in emergency medical (EM) journals. However, unlike other study designs, there are no standards for reporting MRRs and very little literature on the methodology for conducting them. The purpose of this article is to provide the reader with methodological guidance regarding the strengths and weaknesses of these types of studies. Key words: medical records; retrospective studies; research design; evidence-based medicine. ACADEMIC EMERGENCY MEDICINE 2004; 11:187-192. WHAT IS A MEDICAL RECORD REVIEW STUDY?The term ''medical record review'' (MRR) refers to any study that uses prerecorded, patient-focused data as the primary source of information to answer a research question. The sources of information include: physician and nursing notes; ambulance call reports; diagnostic tests (e.g., electrocardiograms, radiographs, laboratory tests); clinic, industry, administrative, and government records; and/or computerized databases.As with any source of data for scientific study, the medical record must ''be capable of providing data that [are] both reproducible and valid.'' 1 This key point is seen as the primary weakness of medical record reviews. WHY SELECT AN MRR STUDY DESIGN?Ideally, a study design is selected because it is the best method of answering the research question. The greatest advantage of the MRR design is that the data are already collected. Emergency health services research makes use of routinely collected data (e.g., emergency department [ED] visits and trauma databases) and chart reviews to address questions about the utilization, appropriateness, process, and outcome of care. Physicians often conduct case series studies based on reviews of charts. Most importantly, MRRs allow us to address research questions that cannot be answered in prospective trials such as: 1) the effects of harmful exposures to which people cannot be randomized; 2) the effects of potentially beneficial exposures to which people cannot be randomized; and 3) the occurrence of rare events in exposures to which people cannot be randomized.Also, there are purposes that are impractical to address with prospective studies, such as: 1) studies of patterns of disease or behavior (e.g., ED visits) over prolonged periods; 2) quality assurance studies; 3) studies involving the sharing of cases to create large (e.g., regional trauma) databases; and 4) pilot studies to provide information for planning prospective trials.However, using medical records will not be useful for measuring phenomena that are commonly not documented.2 Therefore, the convenience of precollected data does not make the MRR study the most appropriate design. HOW ARE STUDY CASES BEST SELECTED FOR MRRs?The two primary differences between MRR and prospective studies are: 1) case selection-in the former, the cases have already occurred and the information on them is mixed with that of all the noneligible subjects; and 2) data quality-the data of MRRs were not o...

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Section: Determining and Reporting Reliabilitymentioning

confidence: 99%

Advanced statistics: Understanding Medical Record Review (MRR) Studies

Worster

Haines

2004

Academic Emergency Medicine

195

151

View full text Add to dashboard Cite

show abstract

Section: Determining and Reporting Reliabilitymentioning

confidence: 99%

Advanced statistics: Understanding Medical Record Review (MRR) Studies

Worster¹

2004

Academic Emergency Medicine

View full text Add to dashboard Cite

Medical record review (MRR) studies have been reported to make up 25% of all scientific studies published in emergency medical (EM) journals. However, unlike other study designs, there are no standards for reporting MRRs and very little literature on the methodology for conducting them. The purpose of this article is to provide the reader with methodolog-ical guidance regarding the strengths and weaknesses of these types of studies. The term ''medical record review'' (MRR) refers to any study that uses prerecorded, patient-focused data as the primary source of information to answer a research question. The sources of information include: physician and nursing notes; ambulance call reports; diagnostic tests (e.g., electrocardiograms, radiographs, laboratory tests); clinic, industry, administrative, and government records; and/or computerized databases. As with any source of data for scientific study, the medical record must ''be capable of providing data that [are] both reproducible and valid.'' 1 This key point is seen as the primary weakness of medical record reviews. WHY SELECT AN MRR STUDY DESIGN? Ideally, a study design is selected because it is the best method of answering the research question. The greatest advantage of the MRR design is that the data are already collected. Emergency health services research makes use of routinely collected data (e.g., emergency department [ED] visits and trauma databases) and chart reviews to address questions about the utilization , appropriateness, process, and outcome of care. Physicians often conduct case series studies based on reviews of charts. Most importantly, MRRs allow us to address research questions that cannot be answered in prospective trials such as: 1) the effects of harmful exposures to which people cannot be randomized; 2) the effects of potentially beneficial exposures to which people cannot be randomized; and 3) the occurrence of rare events in exposures to which people cannot be randomized. Also, there are purposes that are impractical to address with prospective studies, such as: 1) studies of patterns of disease or behavior (e.g., ED visits) over prolonged periods; 2) quality assurance studies; 3) studies involving the sharing of cases to create large (e.g., regional trauma) databases; and 4) pilot studies to provide information for planning prospective trials. However, using medical records will not be useful for measuring phenomena that are commonly not documented. 2 Therefore, the convenience of precol-lected data does not make the MRR study the most appropriate design.

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“…The reliability of data extraction from medical records is a noted concern [43]. Reliability was, therefore, enhanced by following the principles advocated by a number of researchers experienced in this method [45,71,72].…”

Section: Discussionmentioning

confidence: 99%

“…Despite some concerns about the reliability of data extraction from medical records [43], MRRs can be advantageous as they do not influence clinical practice by observing the consultation [44] and it is a time-efficient method of collecting a large amount of data [45]. However, the researcher is reliant upon clinicians accurately recording the information in the medical records [45].…”

Section: Methodsmentioning

confidence: 99%

The assessment of weight status in children and young people attending a spina bifida outpatient clinic: a retrospective medical record review

McPherson

Swift

Yung

et al. 2013

Disability and Rehabilitation

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PurposeChildren with disabilities are two to three times more likely to become overweight or obese than typically developing children. Children with spina bifida (SB) are at particular risk, yet obesity prevalence and weight management with this population are under-researched. This retrospective chart review explored how weight is assessed and discussed in a children’s SB outpatient clinic.MethodHeight/weight data were extracted from records of children aged 2–18 with a diagnosis of SB attending an outpatient clinic at least once between June 2009–2011. Body mass index was calculated and classified using Centers for Disease Control and Prevention cut-offs. Notes around weight, diet and physical/sedentary activities were transcribed verbatim and analysed using descriptive thematic analysis.ResultsOf 180 eligible patients identified, only 63 records had sufficient data to calculate BMI; 15 patients were overweight (23.81%) and 11 obese (17.46%). Weight and physical activity discussions were typically related to function (e.g. mobility, pain). Diet discussions focused on bowel and bladder function and dietary challenges.ConclusionsAnthropometrics were infrequently recorded, leaving an incomplete picture of weight status in children with SB and suggesting that weight is not prioritised. Bowel/bladder function was highlighted over other benefits of a healthy body weight, indicating that health promotion opportunities are being missed.Implications for RehabilitationIt is important to assess, categorise and record anthropometric data for children and youth with spina bifida as they may be at particular risk of excess weight.Information around weight categorisation should be discussed openly and non-judgmentally with children and their families.Health promotion opportunities may be missed by focusing solely on symptom management or function.Healthcare professionals should emphasise the broad benefits of healthy eating and physical activity, offering strategies to enable the child to incorporate healthy lifestyle behaviours appropriate to their level of ability.

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Reliability associated with the abstraction of data from medical records for inclusion in an information system for persons with a traumatic brain injury

Abstract: The results suggest that clinicians using standardized procedures can reliably extract important data pertaining to personal history, impairments, and disabilities relating to sensorimotor function. Some potential sources of error are identified and recommendations are presented.

Cited by 9 publications

References 34 publications

Advanced statistics: Understanding Medical Record Review (MRR) Studies

Advanced statistics: Understanding Medical Record Review (MRR) Studies

Advanced statistics: Understanding Medical Record Review (MRR) Studies

The assessment of weight status in children and young people attending a spina bifida outpatient clinic: a retrospective medical record review

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