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

• Published in: Journal of clinical epidemiology 2008-10, Vol.61 (10), p.1073-1079
• Main Authors: Gravely-Witte, Shannon, Stewart, Donna E, Suskin, Neville, Higginson, Lyall, Alter, David A, Grace, Sherry L
• Format: Article
• Language: English
• Subjects: Aged; Biological and medical sciences; Blood pressure; Body mass index; Cardiologist; Cardiology; Cardiology. Vascular system; Cardiovascular diseases; Cardiovascular Diseases - epidemiology; Cardiovascular Diseases - etiology; Clinical Competence; Completeness; Concordance; Diabetes; Diabetes Mellitus - epidemiology; Documentation; Dyslipidemias - complications; Dyslipidemias - epidemiology; Epidemiologic Methods; Epidemiology; Female; Genetics; Heart; High density lipoprotein; Humans; Hypertension; Hypertension - complications; Hypertension - epidemiology; Internal Medicine; Male; Medical charts; Medical Records - standards; Medical sciences; Middle Aged; Obesity; Ontario - epidemiology; Outpatient Clinics, Hospital; Patient self-report; Risk assessment; Risk factors; Self Disclosure; Smoking; Smoking - adverse effects; Smoking - epidemiology; Socioeconomic Factors
• ISSN: 0895-4356; 1878-5921
• DOI: 10.1016/j.jclinepi.2007.11.017

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 ĸ, 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.