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

J Clin Epidemiol. 2008 Oct;61(10):1073-9. doi: 10.1016/j.jclinepi.2007.11.017. Epub 2008 Apr 14.

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 k, 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.

Publication types

  • Multicenter Study
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Aged
  • Cardiovascular Diseases / epidemiology
  • Cardiovascular Diseases / etiology*
  • Clinical Competence
  • Diabetes Mellitus / epidemiology
  • Dyslipidemias / complications
  • Dyslipidemias / epidemiology
  • Epidemiologic Methods
  • Female
  • Humans
  • Hypertension / complications
  • Hypertension / epidemiology
  • Male
  • Medical Records / standards*
  • Middle Aged
  • Ontario / epidemiology
  • Outpatient Clinics, Hospital
  • Self Disclosure
  • Smoking / adverse effects
  • Smoking / epidemiology
  • Socioeconomic Factors