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

Health Serv Res. 2002 Apr;37(2):483-98. doi: 10.1111/1475-6773.033.


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

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

Study design: 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.

Data collection: 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.

Principal findings: 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.

Conclusions: 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.

Publication types

  • Comparative Study
  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • Aged
  • Algorithms
  • Bias
  • California
  • Connecticut
  • Health Services Research
  • Hospitals / standards*
  • Humans
  • Iatrogenic Disease / epidemiology
  • Medical Audit*
  • Medical Records*
  • Medical Staff, Hospital
  • Medicare / standards*
  • Nursing Audit*
  • Nursing Staff, Hospital
  • Postoperative Complications / epidemiology
  • Professional Review Organizations / standards*
  • Sentinel Surveillance
  • Software