title: Lessons in Medical Record Abstraction from the Prostate, Lung, Colorectal, and Ovarian (PLCO) National Screening Trial.
abstract: The most rigorous and accurate approach to evaluating clinical events in cancer screening studies is to use data obtained through medical record abstraction (MRA). Although MRA is complex, the particulars of the procedure-such as the specific training and quality assurance processes, challenges of implementation, and other factors that influence the quality of abstraction--are usually not described in reports of studies that employed the technique. In this paper, we present the details of MRA activities used in the Prostate, Lung, Colorectal, and Ovarian (PLCO) Cancer Screening Trial, which used MRA to determine primary and secondary outcomes and collect data on other clinical events. We describe triggers of the MRA cycle and the specific tasks that were part of the abstraction process. We also discuss training and certification of abstracting staff, and technical methods and communication procedures used for data quality assurance. We include discussion of challenges faced and lessons learned.
authors.forename: Latifa
authors.initials: L
authors.lastname: Bazzi
authors.forename: Lois E
authors.initials: LE
authors.lastname: Lamerato
authors.forename: Julie
authors.initials: J
authors.lastname: Varner
authors.forename: Vicki L
authors.initials: VL
authors.lastname: Shambaugh
authors.forename: Jill E
authors.initials: JE
authors.lastname: Cordes
authors.forename: Lawrence R
authors.initials: LR
authors.lastname: Ragard
authors.affiliation: Department of Public Health Sciences, Henry Ford Health System, Detroit, MI USA. llamera1@hfhs.org.
authors.forename: Pamela M
authors.initials: PM
authors.lastname: Marcus
mesh_terms: D015179:Colorectal Neoplasms / Q000175:diagnosis; D055088:Early Detection of Cancer / Q000379:methods*; D005260:Female; D006801:Humans; D016247:Information Storage and Retrieval / Q000706:statistics & numerical data*; D008175:Lung Neoplasms / Q000175:diagnosis; D008297:Male; D008403:Mass Screening / Q000458:organization & administration; D008499:Medical Records / Q000706:statistics & numerical data*; D016347:Medical Records Systems, Computerized / Q000706:statistics & numerical data*; D015337:Multicenter Studies as Topic; D054547:National Cancer Institute (U.S.); D009369:Neoplasms / Q000175:diagnosis* / Q000473:pathology; D010051:Ovarian Neoplasms / Q000175:diagnosis; D011471:Prostatic Neoplasms / Q000175:diagnosis; D011785:Quality Assurance, Health Care; D016032:Randomized Controlled Trials as Topic; D014481:United States