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J Clin Epidemiol. 2008 Oct;61(10):1073-9. doi: 10.1016/j.jclinepi.2007.11.017. Epub 2008 Apr 14.

Cardiologists' charting varied by risk factor, and was often discordant with patient report.

Author information

1
University Health Network Women's Health Program, 200 Elizabeth St., Toronto, Ontario, Canada. sgravely@yorku.ca

Abstract

OBJECTIVE:

To assess the completeness of cardiac risk factor documentation by cardiologists, and agreement with patient report.

STUDY DESIGN AND SETTING:

A total of 68 Ontario cardiologists and 789 of their ambulatory cardiology patients were randomly selected. Cardiac risk factor data were systematically extracted from medical charts, and a survey was mailed to participants to assess risk factor concordance.

RESULTS:

With regard to completeness of risk factor documentation, 90.4% of charts contained a report of hypertension, 87.2% of diabetes, 80.5% of dyslipidemia, 78.6% of smoking behavior, 73.0% of other comorbidities, 48.7% of family history of heart disease, and 45.9% of body mass index or obesity. Using Cohen's k, there was a concordance of 87.7% between physician charts and patient self-report of diabetes, 69.5% for obesity, 56.8% for smoking status, 49% for hypertension, and 48.4% for family history.

CONCLUSION:

Two of four major cardiac risk factors (hypertension and diabetes) were recorded in 90% of patient records; however, arguably the most important reversible risk factors for cardiac disease (dyslipidemia and smoking) were only reported 80% of the time. The results suggest that physician chart report may not be the criterion standard for quality assessment in cardiac risk factor reporting.

PMID:
18411042
PMCID:
PMC2924367
DOI:
10.1016/j.jclinepi.2007.11.017
[Indexed for MEDLINE]
Free PMC Article

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