Hospital case notes and medical audit: evaluation of non-response

Stroke care: how do we measure quality?

The purpose of this paper is to review the methods used to measure quality of stroke care. Relevant articles were searched for on Medline using the following key words: stroke, quality, outcome of care, process of care, structure of care. Articles that examined how to measure the quality of stroke care and that examined difficulties in the measurement of care outcomes, processes, and structures were selected. Selected articles were reviewed to summarise methods used to measure quality of stroke care and the primary outcome measures of the studies were extracted. Conclusions were drawn about the best ways to measure the quality of stroke care. Practical problems in using outcome measures to monitor quality of care include the consequences of case mix and difficulties in risk adjustment. Clinicians may use process measures to understand differences in outcome. Once a process of care has been linked to an outcome measure, this care process should be measured. The national sentinel audit for stroke is an audit tool used to examine the quality of the processes of stroke care.

Clinical governance in primary care groups: the feasibility of deriving evidence-based performance indicators

OBJECTIVES

To test the feasibility of deriving comparative indicators in all the practices within a primary care group.

DESIGN

A retrospective audit using practice computer systems and random note review.

SETTING

A primary care group in southern England.

SUBJECTS

All 18 general practices in a primary care group.

MAIN OUTCOME MEASURES

Twenty six evidence-based process indicators including aspirin therapy in high risk patients, detection and control of hypertension, smoking cessation advice, treatment of heart failure, raised cholesterol levels in those with established cardiovascular disease, and the treatment of atrial fibrillation. Feasibility was tested by examining whether it was possible to derive these indicators in all the practices; the problems and constraints incurred when collecting data; the variations in indicator values between practices in both their identification of diseases and in the uptake of various interventions; the possible reasons for these variations; and the cost of generating such indicators.

RESULTS

It was possible to derive eight indicators in all practices and in three practices all 26 indicators. The median number of indicators derived was 12 with two practices able to generate eight. There was considerable variation in the use of computers between practices and in the ability and ease of various practice computer systems to generate indicators. Practices varied greatly in the identification of diseases and in the uptake of effective interventions. Variation in identification of ischaemic heart disease could not be explained by a higher prevalence in practices with a more deprived population. The cost of generating these indicators was 5300 Pounds.

CONCLUSION

Comparative evidence-based indicators, used as part of clinical governance in primary care groups, could have the potential to turn evidence into everyday practice, to improve the quality of patient care, and to have an impact on the population's health. However, to derive such indicators and to be able to make meaningful comparisons primary care groups need greater conformity and compatibility of computer systems, improved computer skills for practice staff, and appropriate funding.

Audit of intensive care burn patients: 1982-92

This study attempts to measure and quantify changes in workload and outcome in clinically ill burn patients admitted to the intensive care unit at this institution over the 11-year period 1982-92. The case notes were studied for all patients admitted to the intensive care unit, 163 cases in total, but information was incomplete in 14. Mortality over the period is compared, using Chi squared analysis with Yates correction, with mortality probability from Bull's chart relating age and body surface area of burn (1971). The trends show increasing admission rates and referral rates to ICU from other hospitals in the region, despite declining admission rates to the regional burn unit as a whole. The duration of stay for admitted patients also shows an increase, the combination of these factors suggesting an increasing workload. There has been no change in outcome over the period. The figures provide a baseline for comparison of outcome in critically ill burn patients and are an important means by which to measure future change.

Mortality league tables: do they inform or mislead?

OBJECTIVE

To examine certain methodological issues related to the publication of mortality league tables, with particular reference to severity adjustment and sample size.

DESIGN

Retrospective analysis of inpatient hospital records.

SETTING

22 hospitals in North West Thames health region for the fiscal year 1992-3.

SUBJECTS

All admissions with a principal diagnosis of aortic aneurysm, carcinoma of the colon, cervical cancer, cholecystectomy, fractured neck of femur, head injury, ischaemic heart disease, and peptic ulcer.

MAIN MEASURES

In hospital mortality rates adjusted by disease severity and calculated on the basis of both admissions and episodes.

RESULTS

The numbers of deaths from specific conditions were often small and the corresponding confidence intervals wide. Rankings of hospitals by death rate are sensitive to adjustment for severity of disease. There are some differences that cannot be explained using routine data.

CONCLUSIONS

Comparison of crude death rates may be misleading. Some adjustment for differences in severity is possible, but current systems are unsatisfactory. Differences in death rates should be studied, but because of the scope for manipulating data, this should be undertaken in a collaborative rather than a confrontational way. Any decision to publish league tables of death rates will be on political rather than scientific grounds.

Incompleteness and retrieval of case notes in a case note audit of colorectal cancer

Hospital case notes are a crucial source of data but are subject to two major biases: incompleteness of data and non-retrieval. To assess these biases in relation to colorectal cancer a study was performed of all cases of colorectal cancer listed in the Thames cancer registry in patients resident in one of four districts in South Thames regions with a diagnosis in 1988. Five medical record sites were involved. Retrieval rate for all case notes for districts combined was 80%. In two districts the rates were too high for further investigation; in the other two respectively patient survival and whether treatment was given were positively associated with retrieval. Among the four districts incompleteness of notes ranged from 38% to 62% for staging, 8% to 40% for treatment, and 70% to 25% for diagnostic tests. Information about treatment was missing in 3% to 20%; survival data were omitted in less than 5%. In all districts completeness of case notes was inadequate and in some non-retrieval compounded the problem. Missing data reduce the quality of cancer registry data and potentially undermine interpretation of epidemiological studies and evaluation of care. Further research is warranted into the standards and resourcing of medical records departments and their effects on retrieval and data quality. Structured proformas could be applied across specialties to identify missing items in case notes, to identify areas where standards are required, or to audit notes where standards have already been agreed. A staging protocol to set standards for colorectal cancer has been adopted in one district, and a prospective audit is being established.

The reliability of Cancer Registry records

Data from the Thames Cancer Registry were compared with data independently abstracted from medical records for 466 patients with confirmed cancer of the bladder diagnosed in 1982. High levels of agreement were observed for five continuous variables and for tumour morphology. Data concerning tumour stage did not clearly distinguish superficial from invasive tumours. Cancer registry data were found to be reliable except for tumour stage which may not be clearly documented in clinical records.

Variations in breast cancer management between a teaching and a non-teaching district

We compared the management and outcome of 999 women with breast cancer presenting between 1982 and 1986 at two centres in a region, one in a teaching district. A comparison was also made with relevant research and The Kings Fund Consensus Statement. The centres frequently differed markedly in the investigations done, diagnostic procedures, histology reporting, axillary sampling, and in the treatment given, also differing from the Consensus with no trend towards it. Survival was better at the teaching centre, both disease-free (N.S.) and overall [odds ratio 1.46 (1.16-1.84) P = 0.0009 unadjusted]. This should be interpreted cautiously as the median follow-up time was relatively short and the study was non-randomised. We conclude that how women with breast cancer are managed is determined as much by where they are referred as by scientific evidence. This indicates the need to introduce standards and protocols into business plans, making audit and service specifications easier.

Survival with bladder cancer, evaluation of delay in treatment, type of surgeon, and modality of treatment

OBJECTIVE

To determine whether length of delay before treatment; specialty and grade of the surgeon; and use made of surgery, radiotherapy, and chemotherapy influenced the survival of patients with cancer of the bladder, after adjusting for case severity.

DESIGN

Retrospective cohort study.

SETTING

South East and South West Thames health regions.

PATIENTS

609 men aged under 75 resident in the South Thames regions who had been registered as new cases of bladder cancer in 1982, 35 of whom were excluded, leaving 574 eligible patients. Analysis was based on 75% retrieval rate for case notes.

MAIN OUTCOME MEASURES

Duration of survival from date of diagnosis of the bladder tumour.

RESULTS

10 prognostic variables were used to adjust for case severity. The median delay from referral to first treatment was 48 (interquartile range 27-84) days. Treatment after a short delay was associated with shorter survival because of the early treatment of more severe cases. Consultants treated 68% of patients, trainee surgeons treated less severe cases. Initial treatment was by a urologist in 67% of cases, but the specialty of the surgeon was not associated with prognosis. The associations of radiotherapy, cystectomy, and systemic chemotherapy with survival were interpreted in terms of selection bias as well as therapeutic effect.

CONCLUSION

Case severity was the most important influence on survival and influenced length of delay before treatment, grade and specialty of the surgeon, and main treatment allocation. After adjusting for case severity variations in these processes of care were not strongly associated with variations in survival.