Concordance between medical records and observations regarding information on coordination of care

Continuity of Care and Coordination of Care: Can they Be Differentiated?

Introduction

Both care continuity and coordination are considered essential elements of health care system. However, little is known about the relationship between care continuity and coordination. This study aimed to differentiate the concepts of care continuity and coordination by developing and testing the reliability and validity of the Combined Outpatient Care Continuity and Coordination Assessment (COCCCA) questionnaire under the universal coverage health care system in Taiwan from a patient perspective.

Methods

Face-to-face interviews were conducted nationwide with community-dwelling older adults selected via stratified multistage systematic sampling with probability-proportional-to-size process. A total of 2,144 subjects completed the questionnaire, with a response rate of 44.67%.

Results

The 16 items of the COCCCA questionnaire were identified via item analysis and principal component analysis (PCA). The PCA generated five dimensions: three continuity-oriented (interpersonal, information sharing and longitudinal between patients and physicians) and two coordination-oriented (information exchange and communication/cooperation among multiple physicians). The second-order confirmatory factor analysis supported the factor structure and indicated that distinct constructs of care continuity and coordination can be identified.

Conclusion

The COCCCA instrument can differentiate the concepts of care continuity and care coordination and has been demonstrated to be valid and reliable in outpatient care settings from a patient perspective.

Improving Documentation of Inpatient Problem List in Electronic Health Record: A Quality Improvement Project

BACKGROUND

The problem list is critical in electronic documentation. It is a powerful tool for clinical decision-making because it provides a concise view of all patient problems in one place and is also a criterion for the Medicare meaningful use incentive program.

OBJECTIVE

To measure the rate of utilization of problem list in electronic health records (EHR) in a pediatric hospital medicine unit and implement sequential interventions to increase the rate of use of problem list to more than 80% by the end of 2015, as measured by at least one documented hospital problem at discharge.

METHODS

We performed a quality improvement process starting with a series of educational interventions. Gradual electronic changes were also made in our EHR to reach our goal.

RESULTS

The use of the problem list for pediatric hospital medicine rose from 47% to 100% in June 2015 and continues to maintain well above the goal of 80%. The problem list usage throughout the children's hospital also rose to 100% within 9 months of project implementation.

CONCLUSIONS

Educational interventions and technology leveraging allowed us to achieve and sustain improvement in appropriate problem list usage.

Pilot study on identification of incidents in healthcare transitions and concordance between medical records and patient interview data

OBJECTIVE

To investigate whether transitional incidents can be identified from the medical records of the general practitioners and the hospital and to assess the concordance of transitional incidents between medical records and patient interviews.

DESIGN

A pilot study.

SETTING

The study was conducted in 2 regions in the Netherlands: a rural and an urban region.

PARTICIPANTS

A purposeful sample of patients who experienced a transitional incident or are at high risk of experiencing transitional incidents.

MAIN OUTCOME MEASURES

Transitional incidents were identified from both the interviews with patients and medical records and concordance was assessed. We also classified the transitional incidents according to type, severity, estimated cause and preventability.

RESULTS

We identified 28 transitional incidents within 78 transitions of which 3 could not be found in the medical records and another 5 could have been missed without the patient as information source. To summarise, 8 (29%) incidents could have been missed using solely medical records, and 7 (25%) using the patients' information exclusively. Concordance in transitional incidents between patient interviews and medical records was 64% (18/28). The majority of the transitional incidents were unsafe situations; however, 43% (12/28) of the incidents reached the patient and 18% (5/28) caused temporary patient harm. Over half of the incidents were potentially preventable.

CONCLUSIONS

This pilot study suggests that the majority of transitional incidents can be identified from medical records of the general practitioner and hospital. With this information, we aim to develop a measurement tool for transitional incidents in the medical record of general practitioner and hospital.

Care coordination between specialty care and primary care: a focus group study of provider perspectives on strong practices and improvement opportunities

Care coordination between the specialty care provider (SCP) and the primary care provider (PCP) is a critical component of safe, efficient, and patient-centered care. Veterans Health Administration conducted a series of focus groups of providers, from specialty care and primary care clinics at VA Medical Centers nationally, to assess 1) what SCPs and PCPs perceive to be current practices that enable or hinder effective care coordination with one another and 2) how these perceptions differ between the two groups of providers. A qualitative thematic analysis of the gathered data validates previous studies that identify communication as being an important enabler of coordination, and uncovers relationship building between specialty care and primary care (particularly through both formal and informal relationship-building opportunities such as collaborative seminars and shared lunch space, respectively) to be the most notable facilitator of effective communication between the two sides. Results from this study suggest concrete next steps that medical facilities can take to improve care coordination, using as their basis the mutual understanding and respect developed between SCPs and PCPs through relationship-building efforts.

What is care coordination?

Introduction

Care coordination is a high-priority area for improvement across healthcare systems, but no consensus definition of care coordination exists.

Methods

This article reviews published definitions of the term “care coordination,” identifies common themes among them, and presents a broad working definition of care coordination.

Results

The review identified 57 unique definitions of care coordination, ranging widely in the scope of participants, settings, and care processes included. Five major themes emerged from the definitions: care coordination involves numerous participants, is necessitated by interdependence among participants and activities, requires knowledge of others’ roles and resources, relies on information exchange, and aims to facilitate appropriate healthcare delivery. Only one definition identified included all five themes, and no one theme was found in a clear majority of definitions. The synthesized themes were incorporated into a broad working definition of care coordination, which has resulted in numerous uses (e.g. guide for systematic review of interventions, development of a measures repository, reference for this journal’s recast focus on the subject).

Discussion

Some ambiguity remains about the definition of care coordination, but the breadth of definitions in use underscores its widespread recognition as important for high-quality care. Even as understanding of care coordination continues to evolve, broad and flexible definitions can help guide the iterative process of developing conceptual models, testing them empirically, refining models, generating evidence about what works best, and ultimately improving the quality of care.

How unique is continuity of care? A review of continuity and related concepts

BACKGROUND

The concept of 'continuity of care' has changed over time and seems to be entangled with other care concepts, for example coordination and integration of care. These concepts may overlap, and differences between them often remain unclear.

OBJECTIVE

In order to clarify the confusion of tongues and to identify core values of these patient-centred concepts, we provide a historical overview of continuity of care and four related concepts: coordination of care, integration of care, patient-centred care and case management.

METHODS

We identified and reviewed articles including a definition of one of these concepts by performing an extensive literature search in PubMed. In addition, we checked the definition of these concepts in the Oxford English Dictionary.

RESULTS

Definitions of continuity, coordination, integration, patient-centred care and case management vary over time. These concepts show both great entanglement and also demonstrate differences. Three major common themes could be identified within these concepts: personal relationship between patient and care provider, communication between providers and cooperation between providers. Most definitions of the concepts are formulated from the patient's perspective.

CONCLUSIONS

The identified themes appear to be core elements of care to patients. Thus, it may be valuable to develop an instrument to measure these three common themes universally. In the patient-centred medical home, such an instrument might turn out to be an important quality measure, which will enable researchers and policy makers to compare care settings and practices and to evaluate new care interventions from the patient perspective.

Creating a culture of thoughtful prescribing

BACKGROUND

In the Netherlands 170,000 patients yearly fall victim to poor communication between health care professionals,with 44% of patients receiving inappropriate therapy as a result. Evidence indicates that this problem may be due to physicians learning to communicate therapeutic content by unstructured means during training.

AIM

To introduce a structured format for creating and communicating therapeutic plans; to provide for students opportunities to practice and feedback on their abilities.

METHODS

We developed the Individualized Therapy Evaluation and Plan (ITEP) for therapeutic decision-making and communication based on the subjective objective assessment and plan note. The therapeutic plans from students of the 2003 cohort were assessed with one simple and one complex case using a 15-point criteria form. Over the next 3 years students were given more practice using the ITEP and the average score on the complex case was tracked and compared to the 2003 cohort.

RESULTS

In cohort 2003, 82% of the students satisfactorily completed the simple case, while only 32% did so with the complex case. In subsequent years, the average scores on the complex case significantly improved from 3.8 to 6.8 with increasing practice.

CONCLUSIONS

Students can select a simple drug regimen, but without practice using the ITEP will not help to deal with multiple disease states.

Measurement of integrated healthcare delivery: a systematic review of methods and future research directions

BACKGROUND

Integrated healthcare delivery is a policy goal of healthcare systems. There is no consensus on how to measure the concept, which makes it difficult to monitor progress.

PURPOSE

To identify the different types of methods used to measure integrated healthcare delivery with emphasis on structural, cultural and process aspects.

METHODS

Medline/Pubmed, EMBASE, Web of Science, Cochrane Library, WHOLIS, and conventional internet search engines were systematically searched for methods to measure integrated healthcare delivery (published - April 2008).

RESULTS

Twenty-four published scientific papers and documents met the inclusion criteria. In the 24 references we identified 24 different measurement methods; however, 5 methods shared theoretical framework. The methods can be categorized according to type of data source: a) questionnaire survey data, b) automated register data, or c) mixed data sources. The variety of concepts measured reflects the significant conceptual diversity within the field, and most methods lack information regarding validity and reliability.

CONCLUSION

Several methods have been developed to measure integrated healthcare delivery; 24 methods are available and some are highly developed. The objective governs the method best used. Criteria for sound measures are suggested and further developments should be based on an explicit conceptual framework and focus on simplifying and validating existing methods.

The nature of informational continuity of care in general practice

BACKGROUND

The availability of patient information to practitioners forms the basis of informational continuity of care. Changes in family practice that now encourage multiphysician clinics have meant that informational continuity of care has become crucial because it is likely that a patient will not continuously see the same doctor. Therefore a review of the nature of informational continuity is useful.

AIM

To answer the question 'How is informational continuity developed in general practice?'.

DESIGN OF STUDY

A rigorous systematic review of relevant electronic databases.

METHOD

Databases were searched for articles answering the research question. Articles focused on family medicine and informational continuity of care were included. Data from reviewed articles were independently extracted and reviewed by two researchers. Conceptual and evidence-based articles were included.

RESULTS

Initially, 193 articles were obtained from all five bibliographic databases; 57 were retained following title and abstract review. Of these, 34 articles were included in the final systematic review. Results show that informational continuity of care is developed using paper/electronic records and remembered information collectively, through a series of doctor-patient consultations over time. Obstacles to its development are practitioners not recording patient information and patients not disclosing important details.

CONCLUSION

These findings have implications for newer styles of primary care that may have a negative impact in the successful management of chronic illnesses in particular.

What are the roles involved in establishing and maintaining informational continuity of care within family practice? A systematic review

BACKGROUND

Central to establishing continuity of care is the development of a relationship between doctor and patient/caregiver. Transfer of information between these parties facilitates the development of continuity in general; and specifically informational continuity of care. We conducted a systematic review of published literature to gain a better understanding of the roles that different parties - specifically doctors, patients, family caregivers, and technology - play in establishing and maintaining informational continuity of care within family practice.

METHODS

Relevant published articles were sought from five databases. Accepted articles were reviewed and appraised in a consistent way. Fifty-six articles were retained following title and abstract reviews. Of these, 28 were accepted for this review.

RESULTS

No articles focused explicitly on the roles involved in establishing or maintaining informational continuity of care within family practice. Most informational continuity of care literature focused on the transfer of information between settings and not at the first point of contact. Numerous roles were, however, were interpreted using the data extracted from reviewed articles. Doctors are responsible for record keeping, knowing patients' histories, recalling accumulated knowledge, and maintaining confidentiality. Patients are responsible for disclosing personal and health details, transferring information to other practitioners (including new family doctors), and establishing trust. Both are responsible for developing a relationship of trust. Technology is an important tool of informational continuity of care through holding important information, providing search functions, and providing a space for recorded information. There is a significant gap in our knowledge about the roles that family caregivers play.

CONCLUSION

The number of roles identified and the interrelationships between them indicates that establishing and maintaining informational continuity of care within family practice is a complex and multifaceted process. This synthesis of roles provided serves as an important resource for continuity of care researchers in general, for the development of continuity of care quality indicators, and for the practice of family medicine.

Randomized controlled trial of an automated problem list with improved sensitivity

PURPOSE

To improve the completeness and timeliness of an electronic problem list, we have developed a system using Natural Language Processing (NLP) to automatically extract potential medical problems from clinical, free-text documents; these problems are then proposed for inclusion in an electronic problem list management application.

METHODS

A prospective randomized controlled evaluation of the Automatic Problem List (APL) system in an intensive care unit and in a cardiovascular surgery unit is reported here. A total of 247 patients were enrolled: 76 in an initial control phase and 171 in the randomized controlled trial that followed. During this latter phase, patients were randomly assigned to a control or an intervention group. All patients had their documents analyzed by the system, but the medical problems discovered were only proposed in the problem list for intervention patients. We measured the sensitivity, specificity, positive and negative predictive values, likelihood ratios and the timeliness of the problem lists.

RESULTS

Our system significantly increased the sensitivity of the problem lists in the intensive care unit, from about 9% to 41%, and even 77% if problems automatically proposed but not acknowledged by users were also considered. Timeliness of addition of problems to the list was greatly improved, with a time between a problem's first mention in a clinical document and its addition to the problem list reduced from about 6 days to less than 2 days. No significant effect was observed in the cardiovascular surgery unit.

Making the case for a qualitative study of medical errors in primary care

In the interest of publicizing examples of funded qualitative health research, the authors share a proposal to the Agency for Healthcare Research and Quality in Washington, D.C., in which they sought to elicit patient stories of preventable problems in their primary health care that were associated with psychological or physical harms. These stories would allow for the construction of a tentative typology of errors and harms as experienced by patients and the contrasting of this with errors and harms reported by primary care physicians in the United States and other countries. The authors make explicit the anticipated concerns of reviewers more accustomed to quantitative research proposals and the arguments and strategies employed to address them.

Continuity of care is associated with well-coordinated care

CONTEXT

The importance of continuity of care as a means to promote care coordination remains controversial.

OBJECTIVE

To determine if there is an association between having an objective measure of continuity of care and parental perception that care is well coordinated.

DESIGN

Cross-sectional study.

SETTING AND POPULATION

Seven hundred fifty-nine patients presenting to a primary care clinic completed surveys that included 5 items from the Components of Primary Care Index (CPCI) that relate to care coordination. MAIN PREDICTOR VARIABLE: A continuity of care index (COC) that quantifies the degree of dispersion of care among providers.

MAIN OUTCOME MEASURES

Likelihood of parents reporting high scores on the care coordination domain as well as each of the 5 individual CPCI items related to care coordination.

RESULTS

Greater continuity of care was associated with higher scores on the CPCI care-coordination domain (P <.001). Continuity of care was also specifically associated with increased odds of agreeing with all 5 individual CPCI items, including reporting that their child's provider "always knows about care my child received in other places" (OR 3.97 [2.11-7.49]), "communicates with the other health care providers my child sees" (OR 2.98 [1.63-5.44]), "knows the results of my child's visits to other doctors" (OR 2.02 [1.08-3.80]), and "always follows up on a problem my child has had, either at the next visit or by phone" (OR 6.20 [2.88-13.35]) and wanting one provider to coordinate all of the health care that the child receives (OR 3.28 [1.48-7.27]).

CONCLUSIONS

Greater continuity of primary care is associated with better care coordination as perceived by parents. Efforts to improve and maintain continuity may be justified.

Comparing quality of care for sexually transmitted diseases in specialized and general clinics

OBJECTIVE

The objective of this study was to compare quality of care for patients with sexually transmitted diseases (STDs) in specialized vs. general clinics.

METHODS

The authors conducted a retrospective chart review evaluating compliance with a set of STD-related process of care quality indicators for adult patients seen in six Los Angeles County clinics (two STD specialized clinics and four general medical clinics).

RESULTS

Thirty-two quality indicators were selected using a modified Delphi process. From March 1, 1996, to June 31, 1996, there were 205 STD-related visits to the two specialized STD clinics and 373 STD-related visits to the four general medical clinics. For patients with "classic" STDs (those for which sexual contact is the primary means of transmission), STD clinics achieved greater compliance than general medical clinics on 14 quality indicators, while general medical clinics achieved greater compliance on 4 indicators.

CONCLUSION

STD clinics provide better overall STD care than general medical clinics. Possible explanations include differences in clinician experience with STD patients and greater use of standardized protocol sheets.

Direct observation of rates of preventive service delivery in community family practice

BACKGROUND

Data on preventive service delivery in primary care practice have been limited by indirect methods of measurement. This study describes directly observed rates of preventive service delivery during outpatient visits to community family physicians.

METHODS

In a multimethod cross-sectional study, research nurses directly observed consecutive patient visits in the offices of 138 family physicians in Northeast Ohio. Patient eligibility for services recommended by the U.S. Preventive Services Task Force was determined from medical record review. Service delivery was assessed by direct observation of outpatient visits. Rates of delivery of specific preventive services were computed. Global summary measures were calculated for health habit counseling, screening, and immunization services.

RESULTS

Among 4,049 visits by established patients with available medical records, wide variation was observed among rates of different preventive services delivered during well-care visits. During illness visits, rates were uniformly low for all preventive services. Counseling services were delivered at only slightly lower rates during illness visits compared to well visits. Patients were up to date on 55% of screening, 24% of immunization, and 9% of health habit counseling services.

CONCLUSION

Rates of preventive service delivery are low. Illness visits are important opportunities to deliver preventive services, particularly health habit counseling, to patients. Preventive service delivery summary scores are useful in providing a patient population perspective on the delivery of preventive services and in focusing attention on delivery of a comprehensive portfolio of services.

Assessing primary care content: four conditions common in community health center practice

Under managed care, community health center (CHC) care patterns will be increasingly subject to outside scrutiny. This article discusses results of medical records reviews assessing quality of care at CHCs for acute otitis media, diabetes, asthma, and hypertension. As a group, these safety net providers meet or exceed prevailing practice across other health care settings; however, there is substantial variation among sites. Regression analyses indicate that the individual CHC used by a patient is the most consistent determinant of whether a patient receives recommended care. Drawing on these results, the article explores approaches for improving care and discusses the implications for performance measurement among CHCs and other safety net providers.

Using large-scale databases to measure outcomes in critical care

The major intent of this article is to describe the availability and potential use of large-scale databases; however, it is first essential to know and understand the basic principles involved in the conduct and interpretation of observational outcomes studies. In this article, the authors briefly overview the design of observational outcomes studies as applied to critical care medicine. Then, criteria for evaluating data sources and for in-depth reviewing of the available data sources from which these observational studies can be conducted are discussed.

How valid are medical records and patient questionnaires for physician profiling and health services research? A comparison with direct observation of patients visits

OBJECTIVES

This study was designed to determine the optimal nonobservational method of measuring the delivery of outpatient medical services.

METHODS

As part of a multimethod study of the content of primary care practice, research nurses directly observed consecutive patient visits to 138 practicing family physicians. Data on services delivered were collected using a direct observation checklist, medical record review, and patient exit questionnaires. For each medical service, the sensitivity, specificity, and Kappa statistic were calculated for medical record review and patient exit questionnaires compared with direct observation. Interrater reliability among eight research nurses was calculated using the Kappa statistic for a separate sample of videotaped visits and medical records.

RESULTS

Visits by 4,454 patients were observed. Exit questionnaires were returned by 74% of patients. Research nurse interrater reliabilities were generally high. The specificity of both the medical record and the patient exit questionnaire was high for most services. The sensitivity of the medical record was low for measuring health habit counseling and moderate for physical examination, laboratory testing, and immunization. The patient exit questionnaire showed moderate to high sensitivity for health habit counseling and immunization and variable sensitivity for physical examination and laboratory services.

CONCLUSIONS

The validity of the medical record and patient questionnaire for measuring delivery of different health services varied with the service. This report can be used to choose the optimal nonobservational method of measuring the delivery of specific ambulatory medical services for research and physician profiling and to interpret existing health services research studies using these common measures.

Comprehensiveness of well child checkups for children receiving Medicaid: a pilot study

Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) is a Medicaid program designed to provide comprehensive well child care for children from low-income families. Each EPSDT checkup should include a physical examination; medical history; assessment of development, nutrition, and immunizations; assessment of hearing, vision, and dental status; and anticipatory guidance. This pilot study of the medical records of 76 children receiving EPSDT checkups in six rural counties in North Carolina provided a preliminary assessment of whether EPSDT checkups included the required components. The study showed that health care providers frequently did not provide adequate documentation of the care provided at the checkup, and it raised questions as to whether children received the required components of the EPSDT checkup.

Use of health records in research: reliability and validity issues

Data extracted from health records are commonly used in studies to address a variety of questions raised by health researchers. However, concern about the reliability and validity of such data generally is limited to an assessment of interrater reliability. Less attention has been paid to the reliability of the health record itself, and to the validity of both the health record and the data extracted from it. This article reviews the distinctions and overlaps among these types of reliability and validity and the factors that influence the validity and reliability of research data obtained from health records. Recommendations to investigators who use health record data in their research projects are offered.

Use of a chart audit: teaching well child care to paediatric house officers

A prospective study employing a randomly assigned control group was conducted to assess the usefulness of a chart audit in teaching paediatric residents the components of well child care. The charts of children less than 5 years of age were reviewed and compared with audit criteria. Per cent compliance scores were calculated for five categories: present history; behaviour-development; family history; past medical history; and physical assessment. Five separate audits (10 charts per resident per audit) were conducted--two prior to giving the residents feedback, one after informing them that a study was being conducted, once a month after giving feedback, and one a year later. There was no significant difference between the baseline scores of the two groups. In addition, there were no significant changes in the experimental group's scores during the first three audits or the control group's scores over the whole 3-year course of the study. However, one month after receiving feedback, the scores of the experimental group improved significantly in present history, behaviour-development, and past history. One year later, the experimental group's scores were lower in every category than in the preceding audit. However, their scores were higher than the control group and the difference reached statistical significance in present history. We conclude that regular chart audits with feedback are a valuable addition to the primary care curriculum in a paediatric residency programme.

Quality of care in public health well child clinics: a neglected issue

The process of well child care in public health clinics was evaluated using a peer review approach based on explicit criteria formulated by the peers themselves. The criteria defined what should be done in order to ensure good preventive care during a client-provider encounter. The data from this study suggest that the traditional goals of public health are being pursued, but that a broader spectrum of preventive care, including attention to the child's psychosocial development, is still lacking.

Assessing the quality of care in a hospital emergency unit: a framework and its application

This article presents a specific application of a general approach to quality assessment by describing in detail both the theoretical and the practical aspects of quality assessment in a hospital emergency unit. The theoretical framework is established by specifying the level and scope of assessment, adopting a definition of quality, modeling emergency care as a succession of phases, specifying evaluative attributes, choosing a method for case selection, and selecting one or more methods of assessment. The practical application of this framework is illustrated using two methods, "tracer" and "trajectory," and selecting specific conditions amenable to assessment with each method.

Concordance of the ambulatory medical record and patients' recollections of aspects of an ambulatory new-patient visit

The ambulatory medical record should provide an accurate account of what took place during an outpatient visit. If it does not, the record cannot be used to judge many aspects of the quality of care, including physician-patient communication. The author evaluated the accuracy of the ambulatory medical record by comparing the results of structured telephone interviews with 40 patients following new-patient visits with audits of the medical records. The evaluation focused on chief complaint and the patient's understanding of the diagnosis, medications and follow-up arrangement. The 95% confidence intervals of concordance rates between interview and audit were [1, 0.68] or better for all measures except understanding of diagnosis [0.73, 0.37]. The generally good rate of concordance between the ambulatory medical record and patient recollection for important indices of physician-patient communication suggests that the ambulatory medical record can be used to evaluate that aspect of ambulatory patient care.

Twenty years of research on the quality of medical care: 1964-1984

Since 1964 we have built on earlier work, with some refinements, particularly in the formulation of explicit criteria of process and outcome; the detailed standardization of case mix when outcomes signify quality; the prespecification of outcomes for follow-up, when adverse outcomes are only the occasion for later assessment of process; a greater emphasis on more subtle organizational characteristics in the study of structure; and the identification of the separate effects of structural attributes by multivariate analysis. We have also paid more systematic attention to questions of measurement, including the veracity and completeness of the record; the procedures of criteria formulation; and the reliability, validity, and screening efficiency of the criteria. A notable advance is the use of decision analysis to identify optimal strategies of care, including the introduction of patient preferences and monetary cost in the specification of such strategies, and the use of decisional algorithms to portray the criteria of quality.

Evaluation of family health education to build social support for long-term control of high blood pressure

Sustaining patient motivation for long-term adherence to drug therapies remains a substantial problem for physicians, other health care providers, the patients themselves, and their families. Other therapeutic requests such as dietary changes and weight control may be even more difficult to maintain than taking pills. As part of a controlled experimental design implemented in an outpatient teaching hospital, an educational program was implemented to improve family member support for medical compliance among hypertensive patients. Family members were interviewed, counseled, and provided with a booklet for the purpose of educating and involving them in the home management of high blood pressure. The booklet identified ways the family member could assist the patient with medication compliance, appointment keeping, as well as diet and weight control. These items were identified and recorded as behavioral objectives in the booklet. Patients were followed for three years to assess long-term outcomes. Results showed a strong statistically significant difference between the experimental and control groups, with the experimental group demonstrating higher levels of appointment-keeping behavior, weight control, and BP under control (all p values less than .001). Analysis of the main effects of the educational program demonstrated that the family member support intervention accounted for the greatest decrease in diastolic blood pressure variability, R2 = .20, p less than .001.

Accuracy of hospital discharge data: five alcohol-related diseases

Accuracy of hospital discharge register data was studied by comparing 954 randomly selected abstracts to the respective medical records. The average percentages of agreement were: date of birth 98, date of admission 96, date of discharge 94, area of residence 93, principal diagnosis 91, disposition on discharge 89, marital status 84, third diagnosis 83, second diagnosis 76, social group 74, occupation 60, and source of admission 49. Accuracy of items was not related to alcohol etiology. An analysis of variance indicated that the number of items in agreement varied by both diagnosis and type of hospital.

The accuracy of prognostic judgments of elderly long-term care patients

Health care professionals' ability to make accurate prognostic judgments for long-term care patients was tested in a study employing quarterly assessments and prognoses for more than 700 patients. Prognoses were made for patients to 'improve', 'decline', or 'remain the same', in physical functioning ability for the next 90 days, after which reassessments took place. Despite substantial information on their patients, these teams of physicians, nurses, physical therapists, and social workers were not very accurate in making prognoses. They were right only about half the time. In general, they tended to be too optimistic. The study has profound implications for policy makers considering reimbursement on the basis of performance related to patient outcome goals. The goals are not likely to have much validity. Health care professionals may also be disturbed by the poor rate of correct guesses about patients' future courses of recovery.

The influence of patient-practitioner agreement on outcome of care

A previous study suggested that patient-practitioner agreement and follow-up in ambulatory care facilitates problem resolution as judged by patients. In this study in another medical practice, practitioner-patient agreement on what problems required follow-up was associated with greater problem resolution as judged by the practitioners regardless of the severity of the problems. In this study, patients did not judge problems mentioned only by themselves to be less improved than problems mentioned by both them and their practitioners. However, in this study more of the problems mentioned only by patients were mentioned in the note of the visit contained in the medical record. Patients expected less and reported less improvements of problems that were neither mentioned by the practitioner nor written in the medical record than was the case for problems listed both by patients and practitioners. The findings of this study confirm those of the previous study in suggesting that practitioner-patient agreement about problems is associated with greater expectations for improvement and with better outcome as perceived by patients. In addition, they indicate that practitioners also report better outcome under the same circumstances.

Presence of observers at patient-practitioner interactions: impact on coordination of care and methodologic implications

In this study in an urban practice, the presence of a neutral observer at follow-up visits enhanced the extent to which practitioners recognized problems which patients had in a previous visit. This improvement was limited to those problems which initially had been mentioned by patients as requiring follow-up. Follow-up of problems initially mentioned by practitioners as needing follow-up was not improved by the observer unless the problem was also mentioned by the patient. Investigators whose information about practitioner-patient interaction depends upon the presence of an observer should be aware of this and possibly other effects. Although routine involvement of a neutral observer in patient-practitioner interactions is probably undesirable, selected deployment of observers or similar alternatives may be useful in situations where practitioner-patient communication is inadequate.