Dataset Information

"Concordance between comorbidity data from patient self-report interviews and medical record documentation".

ABSTRACT: Comorbidity is an important adjustment measure in research focusing on outcomes such as health status and mortality. One recurrent methodological issue concerns the concordance of comorbidity data obtained from different reporting sources. The purpose of these prospectively planned analyses was to examine the concordance of comorbidity data obtained from patient self-report survey interviews and hospital medical record documentation.Comorbidity data were obtained using survey interviews and medical record entries from 525 hospitalized Acute Coronary Syndrome patients. Frequencies and descriptive statistics of individual and composite comorbidity data from both sources were completed. Individual item agreement was evaluated with simple and weighted kappas, Spearman Rho coefficients for composite scores.On average, patients reported more comorbidities during their patient survey interviews (mean = 1.78, SD = 1.99) than providers had documented in medical records (mean = 1.27, SD = 1.43). Higher proportions of positive responses were obtained from self-reports compared to medical records for all conditions except congestive heart failure and renal disease. Older age and higher depressive symptom levels were significantly associated with poorer levels of data concordance.These results demonstrate that survey comorbidity data from ACS patients may not be entirely concordat with medical record documentation. In the absence of a gold standard, it is possible that hospital records did not include all pre-admission comorbidities and these patient survey interview methods may need to be refined. Self-report methods to facilitate some patients' complete recall of comorbid conditions may need to be refined by health services researchers.ClinicalTrials.gov NCT00416026.

SUBMITTER: Corser W

PROVIDER: S-EPMC2346463 | biostudies-other | 2008 Apr

REPOSITORIES: biostudies-other

ACCESS DATA

Publications

"Concordance between comorbidity data from patient self-report interviews and medical record documentation".

Corser William W Sikorskii Alla A Olomu Ade A Stommel Manfred M Proden Camille C Holmes-Rovner Margaret M

BMC health services research 20080416

<h4>Background</h4>Comorbidity is an important adjustment measure in research focusing on outcomes such as health status and mortality. One recurrent methodological issue concerns the concordance of comorbidity data obtained from different reporting sources. The purpose of these prospectively planned analyses was to examine the concordance of comorbidity data obtained from patient self-report survey interviews and hospital medical record documentation.<h4>Methods</h4>Comorbidity data were obtain ...[more]

PMID: 18416841

Similar Datasets

Project description:The search for a reliable, valid and cost-effective comorbidity risk adjustment method for outcomes research continues to be a challenge. The most widely used tool, the Charlson Comorbidity Index (CCI) is limited due to frequent missing data in medical records and administrative data. Patient self-report data has the potential to be more complete but has not been widely used. The purpose of this study was to evaluate the performance of the Self-Administered Comorbidity Questionnaire (SCQ) to predict functional capacity, quality of life (QOL) health outcomes compared to CCI medical records data.An SCQ-score was generated from patient interview, and the CCI score was generated by medical record review for 525 patients hospitalized for Acute Coronary Syndrome (ACS) at baseline, three months and eight months post-discharge. Linear regression models assessed the extent to which there were differences in the ability of comorbidity measures to predict functional capacity (Activity Status Index [ASI] scores) and quality of life (EuroQOL 5D [EQ5D] scores).The CCI (R2 = 0.245; p = 0.132) did not predict quality of life scores while the SCQ self-report method (R2 = 0.265; p < 0.0005) predicted the EQ5D scores. However, the CCI was almost as good as the SCQ for predicting the ASI scores at three and six months and performed slightly better in predicting ASI at eight-month follow up (R2 = 0.370; p < 0.0005 vs. R2 = 0.358; p < 0.0005) respectively. Only age, gender, family income and Center for Epidemiologic Studies-Depression (CESD) scores showed significant association with both measures in predicting QOL and functional capacity.Although our model R-squares were fairly low, these results show that the self-report SCQ index is a good alternative method to predict QOL health outcomes when compared to a CCI medical record score. Both measures predicted physical functioning similarly. This suggests that patient self-reported comorbidity data can be used for predicting physical functional capacity and QOL and can serve as a reliable risk adjustment measure. Self-report comorbidity data may provide a cost-effective alternative method for risk adjustment in clinical research, health policy and organizational improvement analyses.Clinical Trials.gov NCT00416026.

Project description:BACKGROUND:Despite the increasing use of medical records to measure quality of care, studies have shown that their validity is suboptimal. The objective of this study is to assess the concordance of cardiovascular care processes evaluated through medical record review and patient self-administered questionnaires (SAQs) using ten quality indicators (TRANSIT indicators). These indicators were developed as part of a participatory research program (TRANSIT study) dedicated to TRANSforming InTerprofessional clinical practices to improve cardiovascular disease (CVD) prevention in primary care. METHODS:For every patient participating in the TRANSIT study, the compliance to each indicator (individual scores) as well as the mean compliance to all indicators of a category (subscale scores) and to the complete set of ten indicators (overall scale score) were established. Concordance between results obtained using medical records and patient SAQs was assessed by prevalence-adjusted bias-adjusted kappa (PABAK) coefficients as well as intraclass correlation coefficients (ICCs) and 95% confidence intervals (95% CI). Generalized linear mixed models (GLMM) were used to identify patients' sociodemographic and clinical characteristics associated with agreement between the two data sources. RESULTS:The TRANSIT study was conducted in a primary care setting among patients (n?=?759) with multimorbidity, at moderate (16%) and high risk (83%) of cardiovascular diseases. Quality of care, as measured by the TRANSIT indicators, varied substantially between medical records and patient SAQ. Concordance between the two data sources, as measured by ICCs (95% CI), was poor for the subscale (0.18 [0.08-0.27] to 0.46 [0.40-0.52]) and overall (0.46 [0.40-0.53]) compliance scale scores. GLMM showed that agreement was not affected by patients' characteristics. CONCLUSIONS:In quality improvement strategies, researchers must acknowledge that care processes may not be consistently recorded in medical records. They must also be aware that the evaluation of the quality of care may vary depending on the source of information, the clinician responsible of documenting the interventions, and the domain of care.

Project description:BackgroundDocumentation in the medical record facilitates the diagnosis and treatment of patients. Few studies have assessed the quality of outpatient medical record documentation, and to the authors' knowledge, none has conclusively determined the correlates of chart documentation. We therefore undertook the present study to measure the rates of documentation of quality of care measures in an outpatient primary care practice setting that utilizes an electronic medical record.MethodsWe reviewed electronic medical records from 834 patients receiving care from 167 physicians (117 internists and 50 pediatricians) at 14 sites of a multi-specialty medical group in Massachusetts. We abstracted information for five measures of medical record documentation quality: smoking history, medications, drug allergies, compliance with screening guidelines, and immunizations. From other sources we determined physicians' specialty, gender, year of medical school graduation, and self-reported time spent teaching and in patient care.ResultsAmong internists, unadjusted rates of documentation were 96.2% for immunizations, 91.6% for medications, 88% for compliance with screening guidelines, 61.6% for drug allergies, 37.8% for smoking history. Among pediatricians, rates were 100% for immunizations, 84.8% for medications, 90.8% for compliance with screening guidelines, 50.4% for drug allergies, and 20.4% for smoking history. While certain physician and patient characteristics correlated with some measures of documentation quality, documentation varied depending on the measure. For example, female internists were more likely than male internists to document smoking history (odds ratio [OR], 1.90; 95% confidence interval [CI], 1.27 - 2.83) but were less likely to document drug allergies (OR, 0.51; 95% CI, 0.35 - 0.75).ConclusionsMedical record documentation varied depending on the measure, with room for improvement in most domains. A variety of characteristics correlated with medical record documentation, but no pattern emerged. Further study could lead to targeted interventions to improve documentation.

Project description:Background:Documentation of information in the health record by pharmacists is vital to patient care. Failure to document, or failure to document appropriately, may have negative effects on patients. Objectives:The primary objective was to determine pharmacists' competency in 18 elements of chart note documentation at 2 tertiary care centres and 1 rehabilitation centre. The secondary objectives were to quantify the number of episodes of documentation by pharmacists, to characterize the clinical activities associated with this documentation, and to determine whether there were differences in level of competency according to years of hospital experience, additional clinical training, and note type. Methods:This study used prospective audit methodology. Notes documented during a 6-week study period (February to April 2015) were assessed using a rubric specifically created to evaluate 18 of the essential elements of documentation, as defined by the Canadian Society of Hospital Pharmacists. Four of the elements of chart note documentation were assessed on a yes/no basis, and Bloom's taxonomy was used to define the level of competency for the other 14 elements. Values were assigned to each level and were then used to calculate mean scores. Results:A total of 115 pharmacist notes, created by 29 of the 35 pharmacists included in the study, were assessed. The mean competency score per pharmacist was 2.2 (standard deviation [SD] 0.3; maximum score 3). Elements of documentation with the highest level of competency were diplomatic tone, conciseness, and clarity; elements with the lowest level of competency were medication list, note title, monitoring, and drug-related problem statements. The most frequent note types concerned drug-related problems (50 [43%]), pharmacokinetics (25 [22%]), and patient education (19 [17%]). Levels of competency were highest for notes related to patient education (mean 2.4, SD 0.2) and lowest for notes concerning drug-related problems (mean 2.1, SD 0.3) and notes providing clarification (mean 2.1, SD 0.3). The level of competency was not significantly affected by additional clinical training or years of hospital experience. Conclusions:Pharmacists in this study documented concisely, clearly, and in a diplomatic tone; however, there was room for improvement in the frequency and elements of chart note documentation in the patient health record.

Dataset Information

"Concordance between comorbidity data from patient self-report interviews and medical record documentation".

Publications

"Concordance between comorbidity data from patient self-report interviews and medical record documentation".

Similar Datasets

OmicsDI is part of the ELIXIR infrastructure

Tweets