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Variability in classification of consultations by content-based descriptors.

B J Mansfield¹, M Ireland, J A Dickinson

¹Department of Health, Housing and Community Services, Canberra, ACT.

The Medical Journal of Australia

|November 4, 1991

Summary

General practitioners showed significant variability in classifying consultations using content-based descriptors. This inconsistency makes patient records unreliable for auditing consultation content or difficulty.

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Area of Science:

General Practice
Medical Informatics
Healthcare Quality Improvement

Background:

Content-based descriptors are used to classify medical consultations.
Reliability of these descriptors in general practice is not well established.

Purpose of the Study:

To assess the reliability of general practitioners (GPs) in using content-based descriptors for consultations.
To test the hypothesis that significant variation exists among GPs regarding consultation classification.

Main Methods:

GPs reviewed videotaped consultations and written records.
Thirty-nine observer GPs assessed 12 GPs' consultations.
Assessments included consultation duration and components (history, examination, problems).

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Main Results:

High variation observed between assessments from records and tapes.
GPs demonstrated significant differences in using descriptors.
No correlation found between GP characteristics and their ratings.
Observer GPs underestimated consultation content and overestimated duration.

Conclusions:

Considerable variation exists in the application of current Australian content-based descriptors.
The general practitioner patient record is unsuitable for auditing consultation content or difficulty.
Standardization or revision of descriptors may be necessary.