Reducing the risk after coronary artery bypass surgery: documentation of risk factors and communication between hospital and general practice

Are we failing to document adequate smoking histories? A brief review 1999-2009

BACKGROUND

Documenting a detailed smoking history is of obvious importance. Failure to adequately document the smoking history may result in the misdiagnosis and management of asthma, and may be associated with a deficiency of care in patients with cardiovascular disease and several other common diseases.

SCOPE

The purpose of this article is to review the evidence over the past decade that demonstrates inadequate documentation of smoking history. A literature search of English language journals from 1999 to 2009 was completed using several databases, including PubMed, MEDLINE, EMBASE, and SCOPUS.

FINDINGS

Fourteen studies demonstrated inadequate documentation of smoking histories by primary care clinicians, specialists, residents, and medical students. Failure to document smoking histories was observed in patients with conditions such as heart failure, coronary artery disease, and asthma. Electronic decision support systems and simple medical record reminders were effective in improving the documentation of smoking histories.

CONCLUSIONS

Failure to adequately document the smoking history appears to be common. Strategies such as electronic decision support systems are needed to correct this problem in order for patients to receive optimal therapy for their appropriate diagnoses.

Living with heart disease after angioplasty: A qualitative study of patients who have been successful or unsuccessful in multiple behavior change

OBJECTIVE

To document values, attitudes, and beliefs that influence behavior change among a diverse group of patients post-angioplasty.

METHODS

Purposive and maximum-variation sampling were used to assemble a demographically diverse patient cohort (N=61) who had been successful or unsuccessful at post-angioplasty multibehavior change. Semistructured interviews and grounded theory methods were used to collect and analyze qualitative data.

RESULTS

Themes showed the following: a) Patients reported surviving a life-threatening event and feared disease recurrence and death; b) the perception of a turning point and self-determination facilitated behavior change; c) social support and spiritual beliefs promoted coping with the uncertainty of living with heart disease; and d) unsuccessful behavior change was related to physical limitations, a sense that "nothing helps," and the belief that angioplasty "cures" heart disease.

CONCLUSION

Lifestyle interventions should be culturally relevant and adapted to physical abilities. Fostering self-determination and social support may promote successful behavior change.

Inadequate documentation of asthma management in hospitalized adult patients

Undocumented patient information in the medical record (MR) is a barrier to providing high quality care. Inadequate documentation has recently been reported for two cardiovascular diseases. This study was designed to evaluate the documentation of asthma management in the MR to determine if it is consistent with the NIH asthma guidelines. We performed a retrospective chart review of patients (ages 18-49) admitted to the hospital with an ICD-9 code for a primary diagnosis of asthma between January 2004 and May 2007. Patients admitted with a hospitalization for >24 hours and had <10 pack per year smoking history were included. We assessed medication regimens, documentation of asthma education, asthma action plans, referrals, and exacerbating factors. There were 233 admissions for 144 unique patients analyzed. At discharge, 85% of patients lacked documentation of asthma education, 97% lacked documentation of a written asthma action plan being given, and 79% did not have referral to an asthma specialist. Respiratory infection was the most common factor associated with admission; 58% of admissions were lacking documentation of the exacerbating factor. Only 47% of patients were receiving inhaled corticosteroids (ICS) prior to admission; 25% of patients did not have ICS prescribed for maintenance therapy upon discharge. Documentation of asthma management, specifically asthma education in the MR, is insufficient and may reflect a deficiency in care. Additionally, an inadequate number of patients were receiving ICS for maintenance therapy. Based on these findings, mechanisms are needed to ensure appropriate documentation and optimal care.

Does physician-patient communication that aims at empowering patients improve clinical outcome? A case study

OBJECTIVE

A case study at the department for heart surgery of an Austrian University Hospital in 2001, examined the outcome of improved communication aimed at empowering patients to be more effective co-producers of recuperation after surgery.

METHODS

Evaluated were the effects of a training program for developing communication skills of health professionals (physicians, physiotherapists, and nurses) along with a reorganization of patient information schemes. The clinical outcomes after four types of surgery (bypass, stent, artificial valve insertion and combination of these) were observed in 100 patients without (control group) and 99 with the intervention administered (intervention group). Two objective and two subjective health outcome parameters were selected for analysis: care level adjusted length of stay in hospital, frequency of post-surgery complications, subjective health, subjective satisfaction with care received. Self-administered breathing exercises were measured as an intermediary outcome parameter.

RESULTS

In the intervention group length of hospital stay was shorter (by 1 day), incidence of post-surgery tachyarrhythmia was reduced (by 15%), transfer to less intensive care levels was faster and patient ratings for communicative quality of care by doctors and nurses were improved.

CONCLUSION

Professional communication aimed at empowering patients to act as co producers can indeed have an effect on clinical outcome.

PRACTICE IMPLICATIONS

Staff training and reorganization of communication schemes can be an effective intervention in hospital care.

Undocumented patient information: an impediment to quality of care

PURPOSE

Poor documentation in medical records might reduce the quality of care and undermine analyses based on retrospective chart reviews. We assessed the documentation of cardiac risk factors and cardiac history in the records of patients hospitalized with myocardial infarction or heart failure.

METHODS

We performed a retrospective cohort study involving direct chart audit of all consecutive hospitalizations for myocardial infarction (n = 2,109) or heart failure (n = 3,392) in Nova Scotia, Canada, from October 15, 1997, to October 14, 1998. The main outcome measures were the documentation rates for prespecified clinical items, including cardiac risk factors and history of myocardial infarction or heart failure, which were recognized as indicators of the quality of care for the conditions under study.

RESULTS

Information was not documented in a high proportion of cases, ranging from 9% (smoking) to 58% (previous history of heart failure) in charts from patients hospitalized for myocardial infarction, and from 19% (smoking) to 69% (hyperlipidemia) in charts from heart failure hospitalizations. Lack of documentation was more common in women and the elderly.

CONCLUSION

Documentation of important clinical information is poor even in the hospital charts of patients with severe conditions. This quality-of-care issue has implications for health services and outcomes research, including the development of report cards.

A classification system of social problems: concepts and influence on GPs' registration of problems

OBJECTIVES

(1) To test lists of problems in the three axes of well-being (physical, mental, and social) with the GPs' collaboration (2) To place the resulting classification in the context of other ones aiming at collecting data about psycho-social aspects of life (assessment, index and classification systems). (3) To test if GPs would be induced to record psychological and social problems more often in their everyday practice, after having been trained to look more closely at them, inter allia with the use of classification and codes.

METHOD

The lists of problems have been initiated by the WHO Department of Mental Health and discussed at an international symposium; they were then tested on the field, first at an international level, then in Belgium. After discussion by 4 Belgian GPs' Teaching Units, they were then improved. In all surveys concerned, general practitioners were asked to collaborate in three ways: opening their usual medical records and collaborating to prospective phases, including one "test phase," i.e., a training session, recording problems with the use of coding lists, and looking for the proper code. Retrospective and prospective approaches were used both before and after this test phase.

RESULTS

(1) The original lists of problems have been improved on the basis of the findings in medical files and in the survey. (2) A conceptual framework is presented for recording social problems, either in everyday practice (i.e., in health records) or in research settings, e.g., for social surveys. It is biaxial: domains and types of problem. (3) Training GPs for using such a coding system drastically increases the number of psycho-social problems, but only during the prospective phases. In the long run older habits prevail again; only the overall number of contacts mentioning a reason increases, together with the number of "other" reasons for encounter (requests, ...).

CONTENTS

(1) Main concepts (section 1). (2) Various tools for measuring psychosocial problems and well-being (section 2). (3) New conceptual fanmework for a classification of psychosocial problems ( 2.2.3). (4) Using the lists: influence on MDs' recording propensity (section 3).