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Résumé
Introduction: La recherche rétrospective est sous-évaluée et sous-utilisée en psychiatrie de l’enfant et de l’adolescent, en
dépit de la richesse des données cliniques pertinentes qui existent dans les dossiers médicaux. Cet article décrit une
approche systématique et scientifique de la recherche en psychiatrie. Méthode: Nous avons mis au point une méthode rétro-
spective d’analyse des dossiers, documentée par la littérature existante. Résultats: Nous présentons une méthode en neuf
points destinée à maximiser les avantages et à minimiser les limites de l’analyse. Conclusions: L’analyse rétrospective des
dossiers est une méthodologie intéressante qui présente des avantages particuliers et peut offrir d’intéressantes possibil-
ités de recherche en psychiatrie. Cette méthode d’étude ne devrait pas être perdue de vue en psychiatrie.
Mots-clés: méthodologie, analyse rétrospective, dossiers médicaux, données d’archive, recherche
1ColumbiaUniversity School of Social Work, New York, New York
2Department of Psychiatry, The Hospital for Sick Children, Toronto, Ontario
3Department of Psychiatry, Faculty of Medicine, University of Toronto, Ontario
4Deputy Vice-Chancellor, RMIT University, Melbourne, Australia
The advantages of conducting chart reviews barriers. The earlier an investigation seeks to
include: a relatively inexpensive ability to incorporate wider input from others, the sooner
research the rich readily accessible existing the benefits of support, expertise, sample
data; easier access to conditions where there recruitment and promotion can be achieved.
is a long latency between exposure and Despite its sound benefits, this step often
disease, allowing the study of rare occur- receives less attention and is rarely recognized
rences; and most importantly, the generation of as a definitive step (Hess, 2004).
hypotheses that then would be tested prospec- Step Two: Literature Review- This stage
tively (Hess, 2004; VonKoss Krowchuk, Moore, involves a systematic review of the literature
& Richardson, 1995; Wu & Ashton, 1997; pertinent to the study’s area of focus, diag-
Worster & Haines, 2004). However, the limita- noses, conditions, demographics, criteria, and
tions of incomplete documentation, including populations. A review of the literature is a stan-
missing charts, information that is unrecover- dard requirement for any research initiative,
able or unrecorded, difficulty interpreting infor- including retrospective chart reviews (Findley &
mation found in the documents (e.g. jargon, Daum, 1989; Hess, 2004; Jansen et al., 2005;
acronyms, photocopies, and microfiches), prob- Worster & Haines, 2004). The importance and
lematic verification of information and difficulty process of conducting literature reviews is well
establishing cause and effect, variance in the established and it is not necessary to dwell on
quality of information recorded by medical pro- this step. However, it is important to note that
fessionals (Dworkin, 1987; Hess, 2004; Pan et an effective literature review requires searching
al., 2005; VonKoss Krowchuk, 1995), have dis- several databases such as MEDLINE,
couraged researchers from adopting this PyschInfo, CINAHL, and EMBASE; it is also
methodology. More developmental work is recommended that Boolean searches be
required to enhance its applicability (Wu & conducted in each database. Librarians and
Ashton, 1997). We have sought to address this information technologists in hospital and
gap in the literature by developing a methodol- university libraries are valuable resources
ogy for conducting retrospective chart review and should be consulted by investigators
research in psychiatry. unfamiliar with conducting literature reviews. In
addition to traditional published articles, con-
Methodological Guidelines: ference proceedings and dissertations are
To extract data effectively and systemati- worthy of consideration. An exhaustive litera-
cally from historical records requires a number ture review will provide the required background
of discrete steps. and will illuminate how other researchers oper-
Step One: Conception- The conception ationalized key concepts or variables.
stage is comprised of two components: Step Three: Proposal Development- The
research formulation and a clinical scan. development of a chart review research pro-
Research formulation involves the process of posal comprises writing the research proposal
articulating the research questions followed by and operationalization of the variables.
the generation of clear hypotheses. Outlining a Common to all research proposals, the con-
research question and hypothesis enables struction of a research proposal must include
investigators to determine feasibility of retro- an executive summary or abstract, introduc-
spective chart review, instead of considering an tion, literature review, research question and
alternative methodology. Early linking of hypotheses, methodology (design, sample,
research methodology to the study’s proposed instruments, and procedure), significance of
hypothesis facilitates an informed approach the study, limitations, budget, references, and
that assists decisions throughout the subse- appropriate appendices. It is also important
quent research stages. that retrospective chart review proposals be
The second conceptual component is con- written with some consideration for future
ducting a clinical scan of the research question prospective studies (Dworkin, 1987; Findley &
and hypothesis. Seeking out clinical expertise Daum, 1989; VonKoss Krowchuk et al., 1995;
in this stage uncovers unanticipated benefits Worster & Haines, 2004). Operationalization of
while identifying potential methodological the study variables in a review consists of two
interconnected and iterative components. First, tion across multiple sites. However, an
the study variables need to be defined; these electronic version is more cost effective in
variables are generally determined by the large investigations, reduces input error (e.g.,
nature and focus of the investigation. Second, predetermined drop down categories), and
study variables are then reviewed in the litera- allows for easier centralization and access
ture to determine how other researchers have to data.
operationalized them in similar or related inves- Finally, researchers need to decide how the
tigations. It is helpful to develop an appendix data will be managed, stored, and analyzed.
comprised of concise definitions and sup- While pen-and-paper systems can be devel-
ported with citations of studies that have simi- oped, it is strongly recommended that a data
larly used each variable. abstraction software package be used (Wu &
Understanding the design of existing health Ashton, 1997). Several data abstraction soft-
records and how the data is recorded is of ware packages exist, such as Microsoft Access
great importance. The following strategies will (Microsoft Corporation, Redmond, Wash) and
assist in this process. First, it has been rec- MedQuest (Fu and Associates, Arlington, Va)
ommended that researchers examine the flow (Allison et al., 2000; Banks, 1998; Worster &
of information, specifically from patient to Haines, 2004). These packages translate the
health record (Jansen et al., 2005) in order to data abstraction instrument into an electronic
identify established char ting protocols, form that can be used for data input, quality
accepted processes of documentation, and the control, and the management of the data
nature of standard documentation (e.g., emer- (e.g. statistical analysis and reporting). Further-
gency notes, diagnostic information, consulta- more, these programs are widely available,
tions, and discharge reports). Second, carefully inexpensive, and user friendly.
inspect a few charts; three to five charts are Step Five: Develop Protocols and
recommended (Findley & Daum, 1989; Smith, Guidelines for Abstraction- For any data
1996). This will provide critical information on abstraction instrument it is essential to
how the patient chart/health record is con- develop a coding manual that provides a clear
structed and documented. Third, consult with set of protocols and guidelines to instruct the
site-specific clinicians to ascertain how patient reviewers in the collection of data (Findley &
information is recorded and documented in Daum, 1989; Hess, 2004; Wu & Ashton,
multi-site studies. A clear definition of the study 1997). This serves as a reference manual as
variables and understanding of health records to how the data will be abstracted from the
provide the essential base for researchers to health record. The manual should list each vari-
development a standardized chart review data able and explain how the variable will be cap-
abstraction instrument. tured in the data abstraction instrument,
Step Four: Data Abstraction Instrument- describe where the variables are located in the
Organization, simplicity and clarity are essen- health record, and provide the required proto-
tial criteria for the development of a uniform cols to extract the data. Protocols with explicit
data abstraction instrument. Data collection criteria are designed to increase the inter-rater
should be organized in a logical order (Smith, reliability of data abstraction (Goldman, 1992;
1996), and when possible should parallel the VonKoss Krowchuk et al., 1995). Consequently,
flow of the information in the health record. protocols generally require revisions, specifi-
Each variable needs a simple and unambigu- cally following the piloting of the study.
ous response section, where the abstractors Step Six: Data Abstraction- To abstract data
can capture the required information. Internal effectively it is essential to understand the
validity and reproducibility of any retrospective specific requirements of each site to determine
study is significantly enhanced in the standard- the procedures needed to select, train, and
ization of the data (Jansen et al., 2005). This manage the study’s data abstractors. Every
data abstraction instrument can be a paper or health care institution has an established set
an electronic document (Allison et al., 2000). A of guidelines, to which all studies must adhere.
paper instrument has some advantages, While many parallels exist across institutions
notably cost effectiveness and easier applica- for conducting a retrospective chart review,
common differences among institutions are the abstraction instrument and the accompanying
procedures for chart procurement, retrieval protocols and guidelines. It has also been
rates, and access to patient charts. A number repor ted that the accuracy of reviewers
of considerations need to be taken in to increases when the individuals know they are
account, such as who may access the charts being monitored (Wu & Ashton, 1997). Finally it
(e.g., hospital employee), the available space is important to the reliability of the investiga-
provided to read the charts (few institutions tion to determine the inter-rater reliability of
allow charts to be removed), the site’s hours of both the data abstraction instrument and the
operation and access, and policies regarding individual data abstractors. This can be accom-
photocopying and use of institutional or per- plished though a pilot investigation and/or
sonal computers. Any of these can potentially random checks.
influence effective data abstraction and require Finally, protocols are intended to resolve
clarity before study commencement. any ambiguous or conflicting data. It is impor-
Data abstractors need to be carefully tant for abstractors to have established man-
selected and trained (Allison et al., 2000; Pan agement procedures to resolve any conflict.
et al., 2005; Wu & Ashton, 1997). It is prefer- Protocols may include scheduled meetings
able to select abstractors with experience in between abstractors to resolve data conflicts,
retrospective research or the area under inves- access to research investigators for clarifica-
tigation. It is also advantageous to select tion, or the establishment of an independent
abstractors from health care professions, adjudication committee for consultation
preferably with advanced levels of educations (Jansen et al., 2005; VonKoss Krowchuk,
(e.g., Master’s Degree). To ensure inter-rater 1995).
reliability it is imperative to have a minimum of Step Seven: Sample- Every retrospective
two abstractors, but it has been recommended chart review requires a statistical power analy-
to have four (Allison et al., 2000). It is impor- sis to determine the appropriate sample size.
tant to determine how many abstractors are Calculating the appropriate sample size is a
required and whether abstractors should be necessary component in all research proposals
project based or site-specific. When possible it and is dependant on the statistical tests used
is preferable to use abstractors across sites in the study. Calculating sample size is beyond
rather than as on-site data collectors (Jansen the scope of this article, but can be accessed
et al., 2005, Jasperse & Ahmed, 1989). An in a literature review or through consultation
alternative practice is to have one or two key with a biostatistician. A rule for quickly deter-
abstractors train, assist, and audit site-specific mining sample size is 10 cases (charts) per
data abstractors. variable, in order to obtain results that are
A standard recommendation is that data likely to be both true and clinically useful
abstractors remain blind to the study hypothe- (Sackett, Haynes, Guyatt, & Tugwell, 1991).
sis to minimize “subjectivity in classification in While the literature generally holds ten events
relation to personal theories about the study’s per predictor as an accepted norm (Findlay &
aims” (Worster & Haines, 2004, p. 189). Daum, 1989; Harrell, Lee, Machar, & Reichert,
Abstractors blind to the hypothesis decrease 1985; Sackett et al., 1991), others have sug-
reviewer bias, specifically the possibility of their gested that it is acceptable to have a minimum
assessment being swayed by knowledge of of seven or five events per predictor (Raykov &
others (e.g., investigators), concern over Wideman, 1995).
adversely effecting the study’s outcome, or In conducting any retrospective char t
interpreting their abstraction as too lenient or review study, sampling refers to the method by
harsh (Allison et al., 2000; Chaplan, Posner, & which study cases or records are selected from
Cheney, 1991; Goldman, 1992; Wu & Ashton, the target population or database (Worster &
1997). Abstractors must become familiar with Haines, 2004). Three commonly used sampling
a health record, be aware where the informa- methods in retrospective chart review are con-
tion is located, and strive to remain objective venience, quota, and systematic sampling. In
(Haley et al., 1980; Smith, 1996). Abstractors convenience sampling, the most common
should be carefully trained with the data method, suitable cases are selected over a
specific time frame; in quota sampling, a pre- Step Eight: Ethics- It is not permissible to
determined number of cases are sought from conduct a research study without ethics
each site or diagnostic determinant; in system- approval from an institutional review board.
atic sampling, every ‘nth’ case is selected from Therefore, it is an important step to obtain
the target population. Ascertaining the most approval from the institutional review board(s)
appropriate sampling method depends on a where the retrospective research will be con-
number of factors including the importance of ducted (Hess, 2004). Further, it is increasingly
probability sampling, the epidemiological becoming standard that researchers conduct-
nature and prevalence of the specific condition, ing retrospective studies publish their ethics
population availability, research budget, and board approval in the methods section
time constraints. (Baldassano et al., 2004; Clayton & Thorne,
The management of missing data poses 2000; Grant, 2005; Henderson et al., 2004;
methodological limitations in conducting chart Preen, Holman, Lawrence, Baynham, &
review research (Hellings, 2004; VonKoss Semmens, 2004;Woogh, 2001). While the
Krowchuk et al., 1995). Rules about how requirements for institutional review boards are
missing data will be handled should be devised standard, each board has their own protocols
before data collection begins (Wu & Ashton, and policies for applicants. It is recommended
1997). In retrospective chart reviews, missing that researchers contact the institution’s
data can result in a hidden or non-response research ethics board coordinator, as they can
bias in the results, where cases with missing provide valuable and time-saving site specific
information may differ from the other cases information and assistance. Any changes to the
(Worster & Haines, 2004). Generally, managing research protocols generally need to be sub-
missing values is treated either by the deletion mitted to the review board for an amended
of the case or variable, or imputing the missing approval.
value through averaging or maximum likelihood Step Nine: Pilot Study- A pilot study is
strategies (Dworkin, 1987; Worster & Haines, essentially a small version of the proposed
2004). In case or variable deletion, the entire research. Pilot studies are critical in any study
case or variable is deleted from the analysis; design (Perry, 2001; Van Teijlingen & Hundley,
however, this can reduce the sample size or 2002). These preliminary investigations typi-
may introduce a hidden bias (Dworkin, 1987). cally lack the sample size that is needed to
Imputing missing responses through statistical determine statistical significance to validate a
analysis is more common in very large comput- hypothesis or evaluate an instrument (Lydiard,
erized databases (Worster & Haines, 2004), 1991; Thompson & Spier, 1989), yet offer
and assumes that missing data are randomly researchers valuable information. Specifically,
absent. The most common maximum likelihood pilot studies allow researchers to assess the
strategy is assigning the missing value as one feasibility of the planned investigation, deter-
response, such as with a “yes” or “no” ques- mine the adequacy of the instrumentation, and
tion where the absence of a “yes” results in an evaluate any potential methodological pitfalls,
immediate “no”. such as data collection strategies (Prescott &
There is no universal method for managing Soeken, 1989). Moreover, pilot studies provide
missing data, but it is imperative that investigators with an opportunity to evaluate
researchers designing, implementing, and con- the reliability of their data abstraction sheet
ducting retrospective chart review research (Smith, 1996), clarify the data abstraction pro-
develop protocols to address this issue. While tocols, determine the frequency with which
the difficulties of missing data can often items are missing from the chart (Wu & Ashton,
be specific to each investigation, strategies 1997), provide information on the institution’s
to manage this phenomenon can be gar- chart retrieval rates and the process of pulling
nered from anticipating common concerns charts, and evaluate any potential sampling
associated with missing data. The most effec- concerns or impact resulting from inclusion and
tive method to determine the development of exclusion criteria (Jansen et al., 2005).
any problems from missing data is to conduct In retrospective chart review investigations,
a pilot study. a general recognized guideline for reliability is
that pilot studies should target ten percent step has highlighted components to improve
of the overall sample (Gabel & Shindledecker, the reliability and validity of this methodology,
1990; Wu & Ashton, 1997). In determining such as finding and accessing appropriate and
the actual pilot sample, the ten percent accurate data, obtaining consistent informa-
guideline needs to be adjusted to account tion, improving inter-rater reliability, uniformly
for any concerns relating to the institution’s training data abstractors, and reducing bias.
retrieval or availability rates and/or par- Further, this model has sought to address
ticipant response rates if consent for their par- many of the limitations within this approach,
ticipation is required. When possible, it is including limiting potential abstraction and
preferable that pilot char ts be randomly management errors, resolving ambiguous data,
procured. managing missing data, and calculating
As described above, reliability is an impor- effective sample size.
tant rationale for conducting a pilot study in this
methodology. Inter-rater reliability is measured Conclusion
as a percentage of agreement when two or The scientific and systematic investigation
more abstractors collect data from the same of existing health records is an important and
chart (Allison et al., 2000). A less frequently valued methodology in health care research,
used form of reliability is intra-rater reliability, specifically in epidemiology, quality assess-
which involves that same abstractor collecting ment studies, and emergency medicine
data from the same chart on two separate (Worster & Haines, 2004; Wu & Ashton, 1997).
occasions. Depending on the variables’ level of Notwithstanding the recognized and consider-
measurement, a Cohen’s kappa (Kappa) rating able benefits of this methodology, retrospective
or an intra-class correlation coefficient (ICC)
research has been undervalued and underuti-
can statistically measure the reliability. It is
lized in psychiatry and mental health disci-
recommended that a minimum of 80% and
plines. While there remain many notable limita-
preferably 95% reliability be achieved for impor-
tions to retrospective chart review research,
tant variables (Allison et al., 2000; Rosen,
including incomplete or missing documenta-
1995), and that variables with reliability below
tion, poorly recorded, and absent information,
70% be reassessed or re-operationalized.
as a methodology it continues to offer numer-
Results ous advantages.
A comprehensive and functional nine-step This article has offered a clear nine-step
method for conducting retrospective char t approach for conducting retrospective chart
review research in psychiatry has been devel- review research that may assist researchers in
oped. See, Table 1: Methodological Steps: psychiatry and mental health to access the
Conducting Retrospective Char t Review benefits of this methodology and minimize its
Research in Psychiatry. limitations. Following these nine steps will
The initial methodological steps begin increase the scientific rigour through a stan-
with the conception of the retrospective dard process. This process guides the clinician
research that facilitates the required literature researcher in the process of conception and
review and subsequent proposal development. development, definition of variables, and sam-
The middle steps centre on the development pling issues. The strategies outlined for pro-
of a data abstraction instrument and neces- curement and abstraction of data will assist in
sary protocols and guidelines, which effec- minimizing limitations and strengthen the relia-
tively guide the retrieval of data. The final bility of the data. This methodology enables cli-
methodological steps focus on the fundamen- nicians to effectively conduct research that can
tal components of retrospective research, inform and add to their practice. Retrospective
including data abstraction, sampling issues, chart review is an important methodology with
ethics approval and conclude with the impor- distinct advantages and has the potential to
tance of conducting a pilot study. This nine-step provide us with valuable research opportuni-
model has sought to maximize benefits and ties. This method of study should not be lost in
minimize limitations of this methodology. Each the field of psychiatry.
2) Literature Review Literature Review • Search more then one Boolean database
• Review the literature (published and
unpublished studies)
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