Discrepancies between explicit and implicit review: physician and nurse assessments of complications and quality

To identify and characterize discrepancies between explicit and implicit medical record review of complications and quality of care.

Forty-two acute-care hospitals in California and Connecticut in 1994.

In a retrospective chart review of 1,025 Medicare beneficiaries age >65, we compared explicit (nurse) and implicit (physician) reviews of complications and quality in individual cases. To understand discrepancies, we calculated the kappa statistic and examined physicians' comments.

With Medicare discharge abstracts, we used the Complications Screening Program to identify and then select a stratified random sample of cases flagged for 1 of 15 surgical complications, 5 medical complications, and unflagged controls. Peer Review Organization nurses and physicians performed chart reviews.

Agreement about complications was fair (kappa = 0.36) among surgical and was moderate (kappa = 0.59) among medical cases. In discordant cases, physicians said that complications were insignificant, attributable to a related diagnosis, or present on admission. Agreement about quality was poor among surgical and medical cases (kappa = 0.00 and 0.13, respectively). In discordant cases, physicians said that quality problems were unavoidable, small lapses in otherwise satisfactory care, present on admission, or resulted in no adverse outcome.

We identified many discrepancies between explicit and implicit review of complications and quality. Physician reviewers may not consider process problems that are ubiquitous in hospitals to represent substandard quality.