Missing hospital records: a confounding variable in retrospective studies

Acquisition and use of clinical data for audit and research

Acquisition of adequate patient data for clinical management is hard enough, but higher quality patient data are needed for clinical audit and research. This article discusses some of the problems of using routine clinical data for audit and research, aspects of data quality, sources of audit or research data and their problems, methods for improving data quality, the benefits and problems of computer-based systems and current trends in the capture and processing of clinical data.

Surveillance and ascertainment of cardiovascular events. The Cardiovascular Health Study

While previous prospective multicenter studies have conducted cardiovascular disease surveillance, few have detailed the techniques relating to the ascertainment of and data collection for events. The Cardiovascular Health Study (CHS) is a population-based study of coronary heart disease and stroke in older adults. This article summarizes the CHS events protocol and describes the methods of surveillance and ascertainment of hospitalized and nonhospitalized events, the use of medical records and other support documents, organizational issues at the field center level, and the classification of events through an adjudication process. We present data on incidence and mortality, the classification of adjudicated events, and the agreement between classification by the Events Subcommittee and the medical records diagnostic codes. The CHS techniques are a successful model for complete ascertainment, investigation, and documentation of events in an older cohort.

Intelligent Medical Record--entry (IMR-E)

This paper describes an automated medical record designed to allow providers to enter patient data at the point of care. The system runs on PCs and Macintoshes and uses a graphical user interface and object-oriented programming to take advantage of current mouse and pen technologies. The provider acquires all relevant patient data by pointing and clicking at selections on input screens, many of which contain anatomical drawings to help the provider quickly and accurately describe patient findings. The system also generates a grammatically correct progress note using the problem-oriented structure. Furthermore, items identified in the assessment and plans portion of the program can be ported to expert systems for medical decisions assistance or to billing systems. The system allows the provider to obtain the necessary information on a focused patient visit in less than 5 min or to enter a complete history and physical.

Catastrophic complications of previous cesarean section

Of 711 patients who were delivered after one or more previous cesarean sections, 17 (2.4%) had an extremely serious complication. Uterine rupture and placenta previa or placenta accreta with accompanying hemorrhage were the major contributors to mortality and major morbidity. Nine uterine ruptures occurred, including five associated with labor with a low transverse uterine scar and one with an unknown scar (1.4% of trials of labor). There were two cases of placenta previa and five with varying degrees of placenta accreta. The nature and frequency of the observed complications emphasize the potentially serious remote consequences of cesarean section.

Pneumonia during pregnancy: has modern technology improved maternal and fetal outcome?

The maternal death rate and rate of preterm delivery associated with pneumonia during pregnancy have not decreased since the introduction of antibiotics four decades ago. We retrospectively reviewed 25 cases of pneumonia during pregnancy; these cases occurred among 32,179 deliveries. Medical complications included: bacteremia, 16%; empyema, 8%; atrial fibrillation, 4%; respiratory failure necessitating mechanical ventilation, 20%. Obstetric complications occurring during the pneumonia episode included: preterm labor, 44%; preterm delivery, 36%. A patient with cystic fibrosis died; one stillbirth and two neonatal deaths occurred. Underlying maternal disease was significantly associated with maternal medical complications (p = 0.023) and preterm delivery (p = 0.012). Significant medical and obstetric complications continue to occur frequently despite modern antimicrobial, tocolytic, and supportive therapy. Underlying maternal disease, including acquired immunodeficiency syndrome and cystic fibrosis, was associated with preterm delivery and neonatal and maternal death.