[通过结构化数字报告和适应症提高慢性鼻炎生物疗法的文件质量?]

IF 0.8 4区 医学 Q4 OTORHINOLARYNGOLOGY Hno Pub Date : 2024-05-30 DOI:10.1007/s00106-024-01488-x
Jan Hagemann, Christopher Seifen, Laura Koll, Manuel Reissig, Barbara Leggewie, Berit Hackenberg, Julia Döge, Kai Helling, Sven Becker, Ludger Klimek, Christoph Matthias, Benjamin-Philipp Ernst
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引用次数: 0

摘要

背景:生物制剂能靶向抑制 2 型炎症,是治疗未得到充分控制的严重慢性鼻炎伴鼻息肉(CRSwNP)的标准附加疗法。尽管使用纸质核对表实现了标准化,但与适应症标准相关的病史和当前检查结果的记录对医生来说仍是一项重大挑战。通过开发基于结构化报告的应用程序,本研究旨在提高记录质量并简化决策过程。方法:在这项研究中,我们开发了一种数字增量工具,用于记录当前的检查结果并检查是否符合适应症标准。该工具在完整性、所需时间和可读性方面与其他核对表进行了比较:结果:在三种记录方案中,每种方案共收集到 20 项检查结果并纳入分析。两种纸质核对表的记录信息内容相当:17.5 ± 5.1/21.7 ± 7.6 分(满分 43 分);P > 0.05。与所有纸质文件相比,使用数字应用程序编写文件的信息含量显著增加。平均得分为 38.25 ± 3.7 分(占最高分的 88.9%;P 结论:使用数字应用软件进行结构化报告是未来的趋势:未来,在 CRSwNP 患者的生物疗法适应症方面,使用应用程序进行结构化报告可取代纸质报告,并在数据质量和结果可追溯性方面带来更多益处。随着未来文件量的增加、数字化进程的推进以及各中心之间联网的可能性,在不久的将来引入应用程序既有可能又经济实惠。
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[Enhanced quality of documentation for biologic therapy of chronic rhinosinusitis through structured digital reporting and indication?]

Background: With targeted inhibition of type 2 inflammation, biologics represent the standard add-on therapy for inadequately controlled severe forms of chronic rhinosinusitis with nasal polyps (CRSwNP). Despite standardization with paper-based checklists, the documentation of medical history and current findings pertinent to indication criteria are a significant challenge for physicians. Through development of an application based on structured reporting, the current study aimed to improve documentation quality and simplify the decision-making process. Previously available paper checklists served as a comparison.

Methods: For this study, a digital incremental tool was programmed to record current findings and check for fulfilment of indication criteria. The tool was compared with other checklists in terms of completeness, time required, and readability.

Results: A total of 20 findings were collected for each of the three documentation options and included in the analysis. Documentation with the two paper-based checklists had comparable information content: 17.5 ± 5.1/21.7 ± 7.6 points out of a maximum of 43 points; p > 0.05. Documentation using the digital application led to a significant increase in information content compared to all paper-based documentation. The average score was 38.25 ± 3.7 (88.9% of maximum; p < 0.001). On average, user satisfaction was high (9.6/10). Use of the digital application was initially more time consuming, but as more cases were documented, the time taken improved significantly.

Conclusion: In the future, structured reporting using apps could replace paper-based reporting for the indication of biologic therapy in CRSwNP patients and offer additional benefits in terms of data quality and traceability of results. The increasing volume of documentation in the future, the progress of digitalization, and the possibility of networking between individual centers make introduction of the app in the near future both likely and economical.

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来源期刊
Hno
Hno 医学-耳鼻喉科学
CiteScore
1.50
自引率
33.30%
发文量
116
审稿时长
4-8 weeks
期刊介绍: HNO is an internationally recognized journal and addresses all ENT specialists in practices and clinics dealing with all aspects of ENT medicine, e.g. prevention, diagnostic methods, complication management, modern therapy strategies and surgical procedures. Review articles provide an overview on selected topics and offer the reader a summary of current findings from all fields of ENT medicine. Freely submitted original papers allow the presentation of important clinical studies and serve the scientific exchange. Case reports feature interesting cases and aim at optimizing diagnostic and therapeutic strategies. Review articles under the rubric ''Continuing Medical Education'' present verified results of scientific research and their integration into daily practice.
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