Journal of Clinical Epidemiology
Volume 61, Issue 10 , Pages 1073-1079 , October 2008

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

  • Shannon Gravely-Witte

      Affiliations

    • University Health Network Women's Health Program, 200 Elizabeth St., Toronto, Ontario, Canada M5G 2C4
    • York University, Norman Bethune College, 222B, 4700 Keele St., Toronto, Ontario, Canada M3J 1P3
    • Corresponding Author InformationCorresponding author. York University, Faculty of Health, Norman Bethune College, 222B, 4700 Keele St., Toronto, Ontario, Canada M3J IP3. Tel.: (416) 736-2100 ext. 20575; fax: (416) 736-5774.
  • ,
  • Donna E. Stewart

      Affiliations

    • University Health Network Women's Health Program, 200 Elizabeth St., Toronto, Ontario, Canada M5G 2C4
    • The University of Toronto, 35 St. George St., Toronto, Ontario, Canada M5S 1A4
  • ,
  • Neville Suskin

      Affiliations

    • London Health Sciences Centre and University of Western Ontario, University Hospital, Room C6-124G, 339 Windermere Rd, London Ontario, Canada N6A 5A5
  • ,
  • Lyall Higginson

      Affiliations

    • University of Ottawa Heart Institute, Room H-3409, 40 Ruskin St., Ottawa, Ontario, Canada K1Y 4W7
  • ,
  • David A. Alter

      Affiliations

    • Institute for Clinical and Evaluative Sciences, G1 06, 2075 Bayview Ave., Toronto, Ontario, Canada M4N 3M5
    • St. Michael's Hospital, 30 Bond St., Toronto, Ontario, Canada M5B 1W8
    • Toronto Rehabilitation Institute, 345 Rumsey Road, Toronto, Ontario, Canada M4G 1R7
  • ,
  • Sherry L. Grace

      Affiliations

    • University Health Network Women's Health Program, 200 Elizabeth St., Toronto, Ontario, Canada M5G 2C4
    • York University, Norman Bethune College, 222B, 4700 Keele St., Toronto, Ontario, Canada M3J 1P3

,Accepted 25 November 2007.

References 

  1. Ministry of Health and Long-Term Care. A guide to better physician documentation. Physician documentation expert panel. 2006.
  2. Roukema J, Los RK, Bleeker SE, van Ginneken AM, van der Lei J, Moll HA. Paper versus computer: feasibility of an electronic medical record in general pediatrics. Pediatrics. 2006;117:15–21
  3. Martin CA. Improving the quality of medical record documentation. J Healthc Qual. 1992;14:16–23
  4. Ashkenazi A, Cooper M, Chemke J, Simon D, Cohen C, Mass N, et al. The quality assurance committee in a general hospital: Its use in improvement of the medical record. Isr J Med Sci. 1992;28:714–717
  5. Schootman M, Jeffe DB, West MM, Aft R. Self-report by elderly breast cancer patients was an acceptable alternative to surveillance, epidemiology, and end results (SEER) abstract data. J Clin Epidemiol. 2005;58:1316–1319
  6. Bush TL, Miller SR, Golden AL, Hale WE. Self-report and medical record report agreement of selected medical conditions in the elderly. Am J Public Health. 1989;79:1554–1556
  7. Skinner KM, Miller DR, Lincoln E, Lee A, Kazis LE. Concordance between respondent self-reports and medical records for chronic conditions: experience from the veterans health study. J Ambul Care Manage. 2005;28:102–110
  8. Okura Y, Urban LH, Mahoney DW, Jacobsen SJ, Rodeheffer RJ. Agreement between self-report questionnaires and medical record data was substantial for diabetes, hypertension, myocardial infarction and stroke but not for heart failure. J Clin Epidemiol. 2004;57:1096–1103
  9. Simpson CF, Boyd CM, Carlson MC, Griswold ME, Guralnik JM, Fried LP. Agreement between self-report of disease diagnoses and medical record validation in disabled older women: Factors that modify agreement. J Am Geriatr Soc. 2004;52:123–127
  10. Canadian Association of Cardiac Rehabilitation . Canadian guidelines for cardiac rehabilitation and cardiavascular disease prevention: enhancing the science, refining the art. Winnipeg, MB: CACRC; 2004;
  11. The Criteria Committee of the New York Heart Association . In: Nomenclature and criteria for diagnosis of diseases of the heart and great vessels. Boston, MA: Little, Brown & Co; 1994;
  12. American Association for Clinical Chemistry. Cardiac Risk Assessment . Available at http://www.labtestsonline.org/understanding/analytes/cardiac_risk/glance.htmlAccessed March 07, 2007
  13. World Health Organization . Obesity: preventing and managing the global epidemic—report of a WHO consultation on obesity. Geneva: WHO; 1997;WHO/NUT/NCD/98.1
  14. Hlatky MA, Boineau RE, Higginbotham MB, Lee KL, Mark DB, Califf RM, et al. A brief self-administered questionnaire to determine functional capacity (the duke activity status index). Am J Cardiol. 1989;64:651–654
  15. R Development Core Team . R: a language and environment for statistical computing. Available at URL http://www.R-project.orgAccessed March 6, 2006
  16. Pinheiro J, Bates D, DebRoy S, Sarkar D. Nlme: linear and nonlinear mixed effects models. 2006;3.1–3.79
  17. Fleiss JL. Statistical methods for rates and proportions. New York: Wiley; 1973;
  18. Landis JR, Koch GG. An application of hierarchical kappa-type statistics in the assessment of majority agreement among multiple observers. Biometrics. 1977;33:363–374
  19. Graham IM. The importance of total cardiovascular risk assessment in clinical practice. Eur J Gen Pract. 2006;12:148–155
  20. Belle SH, Berk PD, Courcoulas AP, Flum DR, Miles CW, Mitchell JE, et al. Safety and efficacy of bariatric surgery: longitudinal assessment of bariatric surgery. Surg Obes Relat Dis. 2007;3:116–126
  21. Thirlby RC, Randall J. A genetic “obesity risk index” for patients with morbid obesity. Obes Surg. 2002;12:25–29
  22. Grace SL, Krepostman S, Brooks D, Jaglal S, Abramson BL, Scholey P, et al. Referral to and discharge from cardiac rehabilitation: key informant views on continuity of care. J Eval Clin Pract. 2006;12:155–163
  23. Dendukuri N, McCusker J, Bellavance F, Cardin S, Verdon J, Karp I, et al. Comparing the validity of different sources of information on emergency department visits: a latent class analysis. Med Care. 2005;43:266–275
  24. Merkin SS, Cavanaugh K, Longenecker JC, Fink NE, Levey AS, Powe NR. Agreement of self-reported comorbid conditions with medical and physician reports varied by disease among end-stage renal disease patients. J Clin Epidemiol. 2007;60:634–642
  25. Luck J, Peabody JW, Dresselhaus TR, Lee M, Glassman P. How well does chart abstraction measure quality? A prospective comparison of standardized patients with the medical record. Am J Med. 2000;108:642–649
  26. Cradock J, Young AS, Sullivan G. The accuracy of medical record documentation in schizophrenia. J Behav Health Serv Res. 2001;28:456–465
  27. Harlow SD, Linet MS. Agreement between questionnaire data and medical records: the evidence for accuracy of recall. Am J Epidemiol. 1989;129:233–248
  28. Daly LE, Mulcahy R, Graham IM, Hickey N. Long term effect on mortality of stopping smoking after unstable angina and myocardial infarction. Br Med J (Clin Res Ed). 1983;287:324–326
  29. Critchley J, Capewell S. Smoking cessation for the secondary prevention of coronary heart disease. Cochrane Database Syst Rev. 2004;1:CD003041
  30. Health Canada . Smoking and heart disease. Available at http://hc-sc.gc.ca/hl-vs/tobac-tabac/body-corps/disease-maladie/heart-coeur/index_e.htmlAccessed October 28, 2007
  31. Haapanen N, Miilunpalo S, Pasanen M, Oja P, Vuori I. Agreement between questionnaire data and medical records of chronic diseases in middle-aged and elderly Finnish men and women. Am J Epidemiol. 1997;145:762–769
  32. Colditz GA, Martin P, Stampfer MJ, Willett WC, Sampson L, Rosner B, et al. Validation of questionnaire information on risk factors and disease outcomes in a prospective cohort study of women. Am J Epidemiol. 1986;123:894–900

PII: S0895-4356(07)00452-0

doi: 10.1016/j.jclinepi.2007.11.017

Journal of Clinical Epidemiology
Volume 61, Issue 10 , Pages 1073-1079 , October 2008