ASSESSMENT OF SYSTEMIC LUPUS-ERYTHEMATOSUS DISEASE-ACTIVITY BY MEDICAL RECORD REVIEW COMPARED WITH DIRECT STANDARDIZED EVALUATION

Objective. Clinical studies of systemic lupus erythematosus (SLE) ofte n necessitate assessment of previous disease activity, which is someti mes only possible by retrospective evaluation of information from the medical record, Using the Systemic Lupus Activity Measure (SLAM), the present study compared an assessment of disease activity obtained by c hart abstraction with a direct clinical assessment. Methods. A chart S LAM was obtained using information abstracted from the clinic notes of 46 patients with SLE who were being followed up at a referral center, Chart SLAM scores were compared with SLAM scores derived from an inde pendent assessor's direct clinical evaluation. Results, Direct SLAM an d chart SLAM scores were correlated (r = 0.67 by Spearman's rank corre lation, P = 0.0001), Chart review scores for disease activity tended t o be lower, but to an inconsistent degree, reflecting both under- and overestimation of disease activity, The overall misclassification rate on a 3-category scale (mild, moderate, or severe activity) was 59%. C onclusion. Although chart SLAM scores were highly correlated with dire ct SLAM scores, misclassification of disease activity by chart review cannot be rectified, Thus, in research, medical record review should n ot be used as a proxy for the direct SLAM, nor should it be considered comparable with clinical assessments in the analysis of disease activ ity.