Cardiologists' charting varied by risk factor, and was often discordant with patient report.
OBJECTIVE
To assess the completeness of cardiac risk factor documentation by cardiologists, and agreement with patient report.


METHODS
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.


CONCLUSIONS
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.
Gravely-Witte
Shannon
S
University Health Network Women's Health Program, 200 Elizabeth St., Toronto, Ontario, Canada. sgravely@yorku.ca
Stewart
Donna E
DE
Suskin
Neville
N
Higginson
Lyall
L
Alter
David A
DA
Grace
Sherry L
SL
D000368:Aged; D002318:Cardiovascular Diseases / Q000453:epidemiology / Q000209:etiology*; D002983:Clinical Competence; D003920:Diabetes Mellitus / Q000453:epidemiology; D050171:Dyslipidemias / Q000150:complications / Q000453:epidemiology; D004812:Epidemiologic Methods; D005260:Female; D006801:Humans; D006973:Hypertension / Q000150:complications / Q000453:epidemiology; D008297:Male; D008499:Medical Records / Q000592:standards*; D008875:Middle Aged; D009864:Ontario / Q000453:epidemiology; D010044:Outpatient Clinics, Hospital; D012650:Self Disclosure; D012907:Smoking / Q000009:adverse effects / Q000453:epidemiology; D012959:Socioeconomic Factors