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Health Serv Res. 2002 Apr;37(2):483-98.

Discrepancies between explicit and implicit review: physician and nurse assessments of complications and quality.

Author information

1
Division of General Medicine and Primary Care, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA.

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 (kappa = 0.36) among surgical and was moderate (kappa = 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 (kappa = 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.

PMID:
12036004
PMCID:
PMC1430369
DOI:
10.1111/1475-6773.033
[Indexed for MEDLINE]
Free PMC Article

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