Discrepancies Between Explicit and Implicit Review: Physician and Nurse Assessments of Complications and Quality

Authors

  • Saul N. Weingart,

  • Roger B. Davis,

  • R. Heather Palmer,

  • Michael Cahalane,

  • Mary Beth Hamel,

  • Kenneth Mukamal,

  • Russell S. Phillips,

  • Donald T. Davies,

  • Lisa I. Iezzoni


This research was supported by the Agency for Health Care Research and Quality, under grant no. R01 HS09099. The views expressed are solely those of the authors.

Address correspondence to Saul N. Weingart, M.D., Ph.D., Staff Physician, Division of General Medicine and Primary Care, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, LY 313, Boston, MA 02215. Roger B. Davis, Sc.D., is a Biostatistician, Division of General Medicine and Primary Care, Beth Israel Deaconess Medical Center, Department of Medicine, Harvard Medical School, Boston, MA. R. Heather Palmer, M.B., B.Ch., S.M., is a Professor, Department of Health Policy and Management, Harvard School of Public Health, Boston, MA. Michael Cahalane, M.D., is a General Surgeon, Department of Surgery, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA. Mary Beth Hamel, M.D., M.P.H., Kenneth Mukamal, M.D., M.P.H., and Russell S.Phillips, M.D., are General Internists. Donald T. Davies, Jr., B.A., is a Research Assistant; and Lisa I. Iezzoni, M.D., M.Sc., is a Health Services Researcher, Division of General Medicine and Primary Care, Beth Israel Deaconess Medical Center, Department of Medicine, Harvard Medical School, Charles A. Dana Research Institute, and the Harvard-Thorndike Library, Boston, MA.

Abstract

Objective. To identify and characterize discrepancies between explicit and implicit medical record review of complications and quality of care.

Setting. Forty-two acute-care hospitals in California and Connecticut in 1994.

Study Design. In a retrospective chart review of 1,025 Medicare beneficiaries age ≥65, we compared explicit (nurse) and implicit (physician) reviews of complications and quality in individual cases. To understand discrepancies, we calculated the kappa statistic and examined physicians' comments.

Data Collection. With Medicare discharge abstracts, we used the Complications Screening Program to identify and then select a stratified random sample of cases flagged for 1 of 15 surgical complications, 5 medical complications, and unflagged controls. Peer Review Organization nurses and physicians performed chart reviews.

Principal Findings. Agreement about complications was fair ( κ=0.36) among surgical and was moderate ( κ=0.59) among medical cases. In discordant cases, physicians said that complications were insignificant, attributable to a related diagnosis, or present on admission. Agreement about quality was poor among surgical and medical cases ( κ=0.00 and 0.13, respectively). In discordant cases, physicians said that quality problems were unavoidable, small lapses in otherwise satisfactory care, present on admission, or resulted in no adverse outcome.

Conclusions. We identified many discrepancies between explicit and implicit review of complications and quality. Physician reviewers may not consider process problems that are ubiquitous in hospitals to represent substandard quality.

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