Medical Record Abstraction Research Articles

Improved Reliability of Stroke Classification Using the TOAST Criteria

P35 PURPOSE. Improve the reliability of stroke subtype classification. BACKGROUND. We previously found that the reliability of stroke subtype assignment using the TOAST criteria was only fair. In a two phase process to improve inter-rater agreement, we first developed a computerized algorithm for diagnositic categorization (Neurology 1999; 52: A243). In this second phase, residual variability related to differences in data abstraction was systematically assessed and reduced. METHODS. To assess baseline levels of inter-rater agreement, 4 physicians first retrospectively assigned TOAST subtype diagnoses for a randomly selected series of 14 patients. These diagnoses were then compared with those assigned by the computerized algorithm. Critical disagreements in data abstraction were identified and remaining variability reduced with the development of standardized abstraction procedures. Inter- and intra-rater reliability were reassessed in separate randomly selected groups of cases. RESULTS. There was fair to moderate agreement between the algorithm-based and physician-assigned diagnoses for the baseline cases (kappa, k = 0.41, 95% CI: 0.28, 0.54), reflecting variation in the abstracted data and/or its interpretation. The development of standardized abstraction procedures improved reliability to a moderate level (k=0.54, 95% CI: 0.26, 0.82). Critical disagreements (primarily due to differences in the interpretations of CT and MRI scans, cardiovascular evaluations, and ultrasound results) were identified and abstraction procedures revised accordingly. Reliability then improved to substantial levels of both inter-rater (k=0.68, 95% CI: 0.44, 0.91) and intra-rater (k=0.74, 95% CI 0.61,0.87) agreement. Half of remaining disagreements were due to ambiguities in the medical record and half related to errors in data abstraction. CONCLUSION. TOAST subtype classifications can be reliably assigned using a computerized algorithm with data obtained through standardized medical record abstraction. This residual variability can be addressed by having two raters classify each case and then identifying and resolving the reason(s) disagreements.

Risk factors for infective endocarditis: oral hygiene and nondental exposures.

The risks of infective endocarditis (IE) associated with various conditions and procedures are poorly defined. This was a population-based case-control study conducted in 54 Philadelphia, Pa-area hospitals from 1988 to 1990. Community-acquired IE cases unassociated with intravenous drug use were compared with matched community residents. Subjects were interviewed for risk factors. Diagnoses were confirmed by expert review of medical record abstracts with risk factor data removed. Cases were more likely than controls to suffer from prior severe kidney disease (adjusted OR [95% CI]=16.9 [1.5 to 193], P:=0.02) and diabetes mellitus (adjusted OR [95% CI]=2.7 [1.4 to 5.2], P:=0.004). Cases infected with skin flora had received intravenous fluids more often (adjusted OR [95% CI]=6.7 [1.1 to 41], P:=0.04) and had more often had a previous skin infection (adjusted OR [95% CI]=3.5 [0.7 to 17], P:=0.11). No association was seen with pulmonary, gastrointestinal, cardiac, or genitourinary procedures or with surgery. Edentulous patients had a lower risk of IE from dental flora than patients who had teeth but did not floss. Daily flossing was associated with a borderline decreased IE risk. Within the limits of the available sample size, the data showed that IE patients differ from people without IE with regard to certain important risk factors but not regarding recent procedures.

Sports Injuries: An Important Cause of Morbidity in Urban Youth

Sports injuries account for substantial morbidity and medical cost. To direct intervention, a population-based study of the causes and types of sports injuries was undertaken. An injury surveillance system was established at all trauma center hospitals that treat residents 10 to 19 years old in the District of Columbia and the Chief Medical Examiner's Office. Medical record abstractions were completed for those seen in an emergency department, admitted to the hospital, or who died from injury June 1996 through June 1998. Seventeen percent (n = 2563) of all injuries occurred while participating in 1 of 6 sports (baseball/softball, basketball, biking, football, skating, and soccer) resulting in an event-based injury rate of 25.0 per 1000 adolescents or 25.0/1000 population year. Rates were higher in males for all sports. The most common mechanisms were falls (E880-888) and being struck by or against objects (E916-918). Hospitalization was required in 2% of visits and there were no deaths. Of those requiring hospitalization, 51% involved other persons, 12% were equipment-related, and 8% involved poor field/surface conditions. Of all baseball injuries, 55% involved ball or bat impact often of the head. Basketball injuries included several injuries from striking against the basketball pole or rim or being struck by a falling pole or backboard. Biking injuries requiring admission included 2 straddle injuries onto the bike center bar and collision with motor vehicles. Of all football injuries, 48 (7%) involved being struck by an opponent's helmet and 63 (9%) involved inappropriate field conditions including falls on or against concrete, glass, or fixed objects. In soccer there were 4 goal post injuries and a large proportion of intracranial injuries. There were 51 probable or clear assaults during sports and an additional 30 to 41 injuries from baseball bat assaults. Many sports including noncontact sports involved injuries of the head suggesting the need for improved head protection. Injuries involving collisions with others and assaults point to the need for supervision and enforcement of safety rules. The 16% of sports injury visits and 20% of hospitalizations related to equipment and environmental factors suggest that at least this proportion of injury may be amenable to preventive strategies. Design change may be warranted for prevention of equipment-related injuries. The many injuries involving inappropriate sports settings suggest the need for and use of available and safe locations for sports.

Lessons Learned in the Process of Stroke Quality Management: Revised tools and strategies in a follow-up study

P229 Objectives Written care protocols and quality improvement efforts have recently been included in published guidelines on care of the ischemic stroke patient. We describe revisions to the quality management process that resulted in increased protocol use at a 469-bed medical school affiliate private hospital. Methods An earlier clinical pathway for ischemic stroke was ineffectively implemented as shown by pathway use in less than half of appropriate cases. A multidisciplinary team addressed barriers identified in that early experience to modify strategies in the development of a new set of quality management tools (QMT) for ischemic stroke. The revised QMT included: standing orders, clinical pathway, NIH Stroke Scale flow sheet, diagnostic summary form, and variance tracking tool. QMT use rates were calculated by medical record abstraction during a 3-month pilot study and physician and nurse usage rates determined. Factors contributing to QMT usage were analyzed. Results Twenty-eight ischemic stroke patients were admitted to the pilot unit during the study. Usage rates for components of the QMT driven by physicians were: standing orders 93%; IV tPA standing orders 100%; and diagnostic summary form 46%. Nurse related QMT usage was: clinical pathway 96%; NIH Stroke Scale flow sheet 75%; and variance tracking tool 75%. Key strategies that contributed to improved implementation were: 1) early involvement and continuous communication between the expanded multidisciplinary team, staff nurses and physicians 2) empowerment of nurses through NIH Stroke Scale training 3) perception of mutual accountability between nurses and physicians through use of QMT documents 4) clearly defined administrative directives. Conclusion Effective implementation of quality management protocols for ischemic stroke requires active participation of related disciplines at working levels, clear administrative support, and mutual accountability of physicians and nurses. Continuous critical appraisal of the process can afford eventual strategic solutions.

Improved Reliability of Stroke Classification Using the TOAST Criteria

P35 PURPOSE. Improve the reliability of stroke subtype classification. BACKGROUND. We previously found that the reliability of stroke subtype assignment using the TOAST criteria was only fair. In a two phase process to improve inter-rater agreement, we first developed a computerized algorithm for diagnositic categorization (Neurology 1999; 52: A243). In this second phase, residual variability related to differences in data abstraction was systematically assessed and reduced. METHODS. To assess baseline levels of inter-rater agreement, 4 physicians first retrospectively assigned TOAST subtype diagnoses for a randomly selected series of 14 patients. These diagnoses were then compared with those assigned by the computerized algorithm. Critical disagreements in data abstraction were identified and remaining variability reduced with the development of standardized abstraction procedures. Inter- and intra-rater reliability were reassessed in separate randomly selected groups of cases. RESULTS. There was fair to moderate agreement between the algorithm-based and physician-assigned diagnoses for the baseline cases (kappa, k = 0.41, 95% CI: 0.28, 0.54), reflecting variation in the abstracted data and/or its interpretation. The development of standardized abstraction procedures improved reliability to a moderate level (k=0.54, 95% CI: 0.26, 0.82). Critical disagreements (primarily due to differences in the interpretations of CT and MRI scans, cardiovascular evaluations, and ultrasound results) were identified and abstraction procedures revised accordingly. Reliability then improved to substantial levels of both inter-rater (k=0.68, 95% CI: 0.44, 0.91) and intra-rater (k=0.74, 95% CI 0.61,0.87) agreement. Half of remaining disagreements were due to ambiguities in the medical record and half related to errors in data abstraction. CONCLUSION. TOAST subtype classifications can be reliably assigned using a computerized algorithm with data obtained through standardized medical record abstraction. This residual variability can be addressed by having two raters classify each case and then identifying and resolving the reason(s) disagreements.

Designing medical record abstraction forms.

Designing medical record abstraction forms.

Stroke rates during the 1980s. The Minnesota Stroke Survey.

The decline in stroke mortality it the United States may have resulted from declining incidence improved survival of stroke patients, or both. We previously reported that stroke patients who were 30 to 74 years old and were treated in Minneapolis/St Paul hospitals in 1990 survived longer than did their counterparts in 1980. In the present study, we examined trends in the rate of hospitalized stroke in Minneapolis/ St Paul between 1980 and 1990. For 1980, 1985, and 1990, we obtained lists of discharge codes (International Classification of Diseases, 9th revision) from Minneapolis/St Paul hospitals, identified hospitalizations for acute cerebrovascular disease, and randomly selected 50% of the cases for medical record abstraction. We counted stroke events in five different ways, which were based on discharge codes as well as diagnostic criteria, and computed age adjusted stroke rates for each year. Stroke mortality in the population was computed for 1960 through 1994. Among men, all five measures of hospitalized stroke attack rate indicated a decline between 1980 and 1985, which ranged from 5% to > 20%. Among women, there was a sharp contrast between trends that relied on discharge codes and trends that relied on diagnostic criteria: the former indicated a decline (4% to 19%), whereas the latter indicated some increase. For the second half of the 1980s, most measures of stroke attack rate in men, all measures of stroke attack rate in women, and measures of stroke incidence in both sexes did not indicate a decline in stroke occurrence in the population. Mortality from stroke among 30- to 74-year-old residents of Minneapolis/St Paul, which declined rapidly during the 1970s and early 1980s, declined slowly, if at all, during the second half of the 1980s and early 1990s. The incidence of stroke may have declined among 30- to 74-year-old residents of Minneapolis/St Paul in the early 1980s. However, we found little indication of such a trend between 1985 and 1990, a period of slow decline or no decline in stroke mortality in that population.

A study of patient satisfaction and adherence to preventive care practice guidelines

Patient satisfaction ratings are being used to judge physicians' quality of care and to determine physician reimbursement. We therefore studied the association between patient satisfaction and the quality of medical care received by patients in physicians' offices. Patient satisfaction was measured in a survey of patients cared for by 48 primary care physicians in a health maintenance organization in Southern California. Evidence that patients were offered or received preventive care services was determined by patient survey and medical record abstraction, respectively. The medical records of 3,249 randomly selected elderly patients (65 to 75 years old) were studied. Of these patients, 2,799 completed a patient satisfaction and preventive care services survey (response rate 86.1%), 2,654 completed a patient satisfaction survey (response rate 81.7%), and 2,258 completed a quality-of-life survey (response rate 69.5%). Patients were generally satisfied with their physicians' care (median satisfaction score 4.2; scale 1 to 5, 5 being most satisfied). Patients who received or were offered mammography, clinical breast examination, influenza vaccine, pneumococcal vaccine, tetanus vaccine, exercise counseling, and smoking cessation counseling were more satisfied with their medical care than those patients who did not (P < 0.001 for all tests). After controlling for the physician who was providing the medical care, there was still a statistically significant relationship between these factors and patient satisfaction. We found a significant association between patient satisfaction and the performance of some but not all preventive care services. However, we cannot be certain whether there is a relationship between patient satisfaction and quality of patient care.

Quality of care for depressed elderly patients hospitalized in the specialty psychiatric units or general medical wards.

Studies to assess quality of care have become increasingly important for research and policy purposes. To evaluate the difference in quality of care between elderly depressed patients hospitalized in specialty psychiatric units and those hospitalized in general medical wards. We reviewed retrospectively the medical charts of 2746 patients with depression hospitalized in 297 general medical hospitals in five different states. Quality of care was assessed by clinical review of explicit and implicit information contained in the medical records of patients in specialty psychiatric units (n = 1295) and general medical wards (n = 1451). We also used other secondary data sources to determine postdischarge outcomes. We found that (1) a higher percentage of admissions on the psychiatric units were considered appropriate, (2) overall psychological assessment was better on the psychiatric unit, (3) patients were more likely to receive psychological services on the psychiatric wards but more likely to receive traditional general medical services on medical wards, (4) there were more inpatient general medical complications on the psychiatric wards, and (5) implicit measures of clinical status at discharge were better for those on the psychiatric unit. Although limited by reliance on medical record abstraction and a retrospective study design, our data indicate that the quality of care for the psychological aspects of the treatment of depression may be better on psychiatric units, while the quality of general medical components of care may be better on general medical wards.

Improved survival of stroke patients during the 1980s. The Minnesota Stroke Survey.

The underlying reasons for the decline in stroke mortality in the United States are not well understood and have been the subject of ongoing debate. This study was undertaken to determine whether survival of hospitalized stroke patients has changed during the 1980s, thereby contributing to the decline in stroke mortality during that period. For the years 1980, 1985, and 1990, we obtained listings of discharge diagnoses from hospitals in the Minneapolis-St Paul metropolitan area and identified all hospitalizations with a discharge diagnosis code of acute cerebrovascular disease according to the International Classification of Diseases, 9th Revision. A 50% random sample of men and women aged 30 to 74 years was selected in each survey for detailed medical record abstraction. Standardized sets of criteria for stroke were then used to validate acute stroke events throughout the 1980s. Each of the three period cohorts of hospitalized stroke patients (1980, 1985, and 1990) was followed for at least 2 years for all-cause mortality end point. A total of 1853 patients met minimal criteria for acute stroke: 564 patients in 1980, 598 patients in 1985, and 691 patients in 1990. Controlling for age, the odds of death within 2 years after stroke were approximately 40% lower in 1990 than in 1980. The relative odds of 2-year death in 1990 (versus 1980) were 0.65 (95% confidence interval, 0.47 to 0.89) and 0.60 (95% confidence interval, 0.42 to 0.85) for men and women, respectively. The improved survival was evident in the short term (28 days) as well as for stroke patients who survived that period. Analysis according to stroke subtype revealed that improved survival of ischemic stroke and specifically of stroke with no apparent cardioembolic source largely accounted for the overall trend. The prognosis of stroke patients who were admitted in a comatose state has not changed during that decade. Despite the absence of any clear major advances in acute stroke therapy, survival of stroke patients substantially improved during the 1980s. The underlying reasons for this unexpected yet remarkable trend remain uncertain but may include improved supportive and rehabilitative care of stroke victims as well as a change in the natural history of the disease.

Risk factors for abomasal volvulus and left abomasal displacement in cattle

Summary A hospital-based case-control study was conducted to evaluate and compare risk factors for abomasal volvulus (av) and left displaced abomasum (lda) in cattle. Medical record abstracts were derived from 17 North American veterinary schools by the Veterinary Medical Data Program for all cattle admitted between Jan 1, 1977 and Dec 31, 1986, and for those with a diagnosis of av or lda. From a total of 108,956 individual cattle records, 1,036 cases of av and 7,695 cases of lda were identified, with a ratio of LDA to AV cases of 7.4 to 1. In-hospital mortality was 23.5% for av and 5.6% for lda. Age, breed, gender, and season each had significant (P &lt; 0.05) effects on risk for av and lda. Risk for av and lda increased with increasing age, with greater risk in cattle aged 4 to 7 years. Dairy cattle were at higher risk of developing av (adjusted odds ratio, 36.4) and lda (adjusted odds ratio, 95.2) than were beef cattle. The odds of AV in Brown Swiss cattle were significantly (P &lt; 0.0001) lower, and the odds of lda in Guernsey cattle were significantly (P &lt; 0.0001) higher than those in Holstein cattle. Female cattle were also at higher risk of developing av (adjusted odds ratio, 3.3) and lda (adjusted odds ratio, 29.1) than were male cattle. The odds of av and LDA varied considerably throughout the year, with the lowest number of cases observed in autumn. Seasonal development of AV differed significantly (P &lt; 0.0001) from that of LDA, with the odds of av and lda being highest in January and March, respectively. The medical records for all cattle with av and lda examined at the teaching hospital over a 10- and 5-year period, respectively, were reviewed, and the time interval since parturition, as well as the existence and nature of concurrent disease, were recorded. Proportionately fewer cases of av than lda developed during the first 2 weeks after parturition (28.3% of av cases vs. 57.0% of lda cases). Concurrent disease existed in 30.4% of av cases and 53.6% of LDA cases, with the rates of concurrent disease differing significantly (P &lt; 0.0001) between the 2 groups. The mis-classification rate for data generated at the teaching hospital was estimated to be 6.5% for av and 5.3% for lda. On the basis of the findings of this study, we hypothesize that: abomasal atony is a prerequisite for av and lda; existence of an abdominal void immediately after parturition facilitates development of AV and lda; normal rumen volume provides a moderately effective barrier against lda; risk of lda does not increase appreciably with advancing pregnancy; and the direction of abomasal displacement (av or lda) after abomasal atony and dilation is influenced principally by rumen volume.