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Am J Med. 2013 Aug;126(8):732-8. doi: 10.1016/j.amjmed.2013.02.017. Epub 2013 Jun 18.

A brief, low-cost intervention improves the quality of ambulatory gastroenterology consultation notes.

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Center for Innovation in Access and Quality, Department of Medicine, San Francisco General Hospital, University of California San Francisco, San Francisco, CA, USA.



Effective communication between primary care providers and specialty providers is important to facilitate high-quality specialty care. Few studies have assessed the quality of communication from specialist to primary care providers or implemented interventions to improve quality. We developed a brief, low-cost intervention designed to improve the quality of ambulatory gastroenterology consultation notes written by fellows and nurse practitioners in our urban health care system.


Six physicians (3 specialists and 3 primary care providers) scored pre- and postintervention notes using an objective quality assessment instrument that had excellent inter-rater reliability. They were blinded to note date, author, and pre/postintervention status. The primary outcome was improvement in Composite Quality Score, an objective, comprehensive assessment of quality. Secondary outcomes included improvements in 3 specific domains, and Global Quality Score (a subjective measure of quality).


Two hundred pre- and 200 postintervention notes written by 6 fellows and 2 nurse practitioners were included. Composite Quality Score improved from 3.74 (of 5) to 4.09 (P <.001 in adjusted analysis). All secondary outcomes improved in adjusted analyses as well. The largest increase was seen in Communication Domain (22% increase). Fellow-written notes had higher scores than nurse practitioner-written notes, but nurse practitioner-written notes improved to a greater degree.


A brief, low-cost intervention significantly improved the quality of ambulatory gastroenterology consultation notes written by fellows and nurse practitioners. Communication between primary care providers and specialists is an important area for further study.


Communication; Consultation and referral; Gastroenterology; Midlevel providers; Primary care; Quality; Specialty care

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