Discrepancies between explicit and implicit review: physician and nurse assessments of complications and quality.

<bold>Objective: </bold>To identify and characterize discrepancies between explicit and implicit medical record review of complications and quality of care.<bold>Setting: </bold>Forty-two acute-care hospitals in California and Connecticut in 1994.<bold>Study Design: </bold>In a retrospective chart review of 1,025 Medicare beneficiaries age >65, we compared explicit (nurse) and implicit (physician) reviews of complications and quality in individual cases. To understand discrepancies, we calculated the kappa statistic and examined physicians' comments.<bold>Data Collection: </bold>With Medicare discharge abstracts, we used the Complications Screening Program to identify and then select a stratified random sample of cases flagged for 1 of 15 surgical complications, 5 medical complications, and unflagged controls. Peer Review Organization nurses and physicians performed chart reviews.<bold>Principal Findings: </bold>Agreement about complications was fair (kappa = 0.36) among surgical and was moderate (kappa = 0.59) among medical cases. In discordant cases, physicians said that complications were insignificant, attributable to a related diagnosis, or present on admission. Agreement about quality was poor among surgical and medical cases (kappa = 0.00 and 0.13, respectively). In discordant cases, physicians said that quality problems were unavoidable, small lapses in otherwise satisfactory care, present on admission, or resulted in no adverse outcome.<bold>Conclusions: </bold>We identified many discrepancies between explicit and implicit review of complications and quality. Physician reviewers may not consider process problems that are ubiquitous in hospitals to represent substandard quality. [ABSTRACT FROM AUTHOR]