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Health Care Quality

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Peer review organizations may need to reconsider the use of physician and nurse reviews of quality of care

Peer review organizations (PROs) frequently use medical record reviews, sometimes performed by nurses and other times by physicians, to determine substandard care. However, nurse and physician reviewers who examine the same medical records often come to substantially different conclusions, according to a study supported by the Agency for Healthcare Research and Quality (HS09099). The study found that agreement between nurses and physicians about complications was only fair to moderate, and agreement about quality of care was poor, only a little better than chance.

When physician reviewers disagreed with nurse reviewers, they usually felt that quality problems were unavoidable, simply small lapses in otherwise satisfactory care, present on admission, or resulted in no adverse outcome. This suggests that physician reviewers may not consider process problems that are common in hospitals to represent substandard quality. It also suggests that the PRO program should be wary of its standard operating procedures, cautions Lisa I. Iezzoni, M.D., M.Sc., of Harvard Medical School. She and colleagues retrospectively examined PRO physician and nurse reviews of complications and care quality in the medical charts of 1,025 elderly Medicare patients.

Nurse and physician agreement about complications was fair among surgical cases and moderate among medical cases. Physicians confirmed complications where nurses did not in up to 14 percent of cases (for example, medication-related errors). Nurses confirmed complications where physicians did not in up to 30 percent of cases (reopening of a surgical site). Agreement about care quality was poor among surgical and medical cases. Physicians confirmed quality problems where nurses did not in up to 31 percent of cases (postprocedural hemorrhage or hematoma). Nurses confirmed quality problems where physicians did not in up to 52 percent of cases (in-hospital hip fracture and falls among surgical patients).

See "Discrepancies between explicit and implicit review: Physician and nurse assessments of complications and quality," by Saul N. Weingart, M.D., Ph.D., Roger B. Davis, Sc.D., Heather Palmer, M.B., B.Ch., S.M., and others, in the April 2002 Health Services Research 37(2), pp. 483-498.

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