Universität zu Köln

Kaur, Sukhvir ORCID: 0009-0001-6252-6193, Meesters, Sophie ORCID: 0000-0002-6174-6573, Schieferdecker, Aneta ORCID: 0009-0008-7354-753X, Dangendorf, Annika, Strohbücker, Barbara, Oubaid, Nikolas ORCID: 0009-0001-0644-3676, Ullrich, Anneke ORCID: 0000-0002-1759-4461, Milke, Viola ORCID: 0000-0003-3072-4790, Oechsle, Karin ORCID: 0000-0002-5183-641X, Schulz, Holger ORCID: 0000-0001-5375-0030, Voltz, Raymond ORCID: 0000-0002-4761-3395 and Kremeike, Kerstin (2025). How to Evaluate Hospital Care in the Dying Phase—Development of a Data Extraction Tool for Retrospective Medical Record Analysis. Journal of Evaluation in Clinical Practice, 31 (5). pp. 1-12. Wiley. ISSN 1356-1294

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Abstract

[Artikel-Nr.: e70174] Background: Hospitals are the most common place of death in European countries, including Germany, where nearly half of the population dies in hospitals, mostly outside specialised palliative care wards. At the same time, quality of hospital care in the dying phase is reported as poor. Although existing (inter‐)national guidelines provide outcome variables, their evaluation of implementation is lacking. This study aims to develop and test a structured tool for data extraction from medical records (MRs) to evaluate hospital care in the dying phase. The provision of such a tool can help to identify needs for improvement of care. Methods: We developed a data extraction tool by operationalizing recommendations for the dying phase of the evidenced‐ based German National Palliative Care Guideline . The tool was used to extract notes from MRs of n = 400 deceased patients of 10 general wards and intensive care units at two University Medical Centres. We analysed the tool's information density and content validity. Descriptive statistics were calculated as frequencies and percentages. Results: The final tool consists of 39 variables in six domains. Initially, 55 variables were derived from guideline recommendations. With regard to content validity, notes for 37 (67%) variables could be extracted from the MRs, while 16 variables were removed due to poor or unclear documentation. Two additional variables were identified inductively and included in the final tool. Notes could be extracted for all domains, while information density (% of MR with notes) varied: (1) Dying process and death ( n = 380, 95.0%), (2) Medication and interventions ( N = 323, 80.7%), (3) Information and involvement of patients and informal caregivers ( n = 155, 38.8%), (4) Symptom assessment ( n = 105, 26.3%), (5) Involvement of specialised palliative care ( n = 78, 19.5%), (6) Goals‐of‐care ( n = 76, 19.0%). Variation in documentation can reflect differences in care provision or recording practices, suggesting a need for documentation standards. Conclusion: The tool enables a structured retrospective analysis of guideline‐recommended aspects of care in the dying phase in MRs, applicable to both general wards and intensive care units. It can support quality improvement by identifying documentation gaps and areas of care improvement, and can contribute to target interventions in different hospital settings. To obtain a comprehensive understanding of the care provided, MR analysis should be combined with other methods and perspectives and tested in other settings. Trial Registration: The study is registered in the German Clinical Trials Register (DRKS00025405).

Item Type:	Article
Creators:	Creators Email ORCID ORCID Put Code Kaur, Sukhvir UNSPECIFIED https://orcid.org/0009-0001-6252-6193 UNSPECIFIED Meesters, Sophie UNSPECIFIED https://orcid.org/0000-0002-6174-6573 UNSPECIFIED Schieferdecker, Aneta UNSPECIFIED https://orcid.org/0009-0008-7354-753X UNSPECIFIED Dangendorf, Annika UNSPECIFIED UNSPECIFIED UNSPECIFIED Strohbücker, Barbara UNSPECIFIED UNSPECIFIED UNSPECIFIED Oubaid, Nikolas UNSPECIFIED https://orcid.org/0009-0001-0644-3676 UNSPECIFIED Ullrich, Anneke UNSPECIFIED https://orcid.org/0000-0002-1759-4461 UNSPECIFIED Milke, Viola UNSPECIFIED https://orcid.org/0000-0003-3072-4790 UNSPECIFIED Oechsle, Karin UNSPECIFIED https://orcid.org/0000-0002-5183-641X UNSPECIFIED Schulz, Holger UNSPECIFIED https://orcid.org/0000-0001-5375-0030 UNSPECIFIED Voltz, Raymond UNSPECIFIED https://orcid.org/0000-0002-4761-3395 UNSPECIFIED Kremeike, Kerstin UNSPECIFIED UNSPECIFIED UNSPECIFIED
URN:	urn:nbn:de:hbz:38-805724
Identification Number:	10.1111/jep.70174
Journal or Publication Title:	Journal of Evaluation in Clinical Practice
Volume:	31
Number:	5
Page Range:	pp. 1-12
Number of Pages:	12
Date:	13 August 2025
Publisher:	Wiley
ISSN:	1356-1294
Language:	English
Faculty:	Faculty of Medicine
Divisions:	Faculty of Medicine > Palliativmedizin > Zentrum für Palliativmedizin Faculty of Medicine > Pflegewissenschaft Faculty of Medicine > Weitere > Centrum für integrierte Onkologie (CIO) Faculty of Medicine > Weitere > Zentrum für Versorgungsforschung Köln
Subjects:	Medical sciences Medicine
Uncontrolled Keywords:	Keywords Language dying in hospital | dying phase | medical record analysis | palliative care | quality of care English
['eprint_fieldname_oa_funders' not defined]:	Publikationsfonds UzK
Refereed:	Yes
URI:	http://kups.ub.uni-koeln.de/id/eprint/80572