Quality of recording of data from patients with type 2 diabetes is not a valid indicator of quality of care. A cross-sectional study.
BACKGROUND
The quality of recording of clinical data in diabetes care in general practices is very variable. It has been suggested that better recording leads to improved glycaemic control.


OBJECTIVE
The purpose of this study was to assess the completeness of recording by GPs of data from type 2 diabetes patients; to compare recorded and missing data; and to investigate the association between completeness and glycaemic control.


METHODS
A cross-sectional survey was carried out in 52 general practices. Medical records were scrutinized for the presence of 11 variables. Examining patients through an active approach completed incomplete records. We compared recorded and unrecorded items. Completeness of recording was determined at both patient and practice levels.


RESULTS
Fifty-two general practices with 1641 type 2 diabetes patients cared for by the GP participated. The frequency of absence of any particular item ranged from 20 to 70%. Weight, systolic blood pressure and HbA(1c) were slightly lower in patients with those items missing on their files, and more such patients were non-smokers (P < 0.05). The percentage of patients with unrecorded variables that exceeded target values ranged from 39 to 75. Neither at practice level nor at patient level was any association between the completeness of the data recording and HbA(1c) found.


CONCLUSIONS
Records often were incomplete, which hampers a systematic approach to care of diabetic patients. However, the lack of association between completeness of data recording and control of glycaemia indicates that improved recording is not a valid indicator of good quality of care.
Goudswaard
Alex N
AN
Julius Center for Health Science and Primary Care, University Medical Center, Utrecht, The Netherlands. lex@goudswaard.cx
Lam
Kahnh
K
Stolk
Ronald P
RP
Rutten
Guy E H M
GE
D000328:Adult; D000368:Aged; D016009:Chi-Square Distribution; D003430:Cross-Sectional Studies; D003924:Diabetes Mellitus, Type 2 / Q000628:therapy*; D005194:Family Practice / Q000592:standards*; D005260:Female; D006801:Humans; D008297:Male; D008499:Medical Records / Q000592:standards*; D008875:Middle Aged; D009426:Netherlands; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D011787:Quality of Health Care