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Results From CRUSADE

Shannon M. Dunlay, MD; Karen P. Alexander, MD; Chiara Melloni, MD; Jennifer L. Kraschnewski, MD; Li Liang, PhD; W. Brian Gibler, MD; Matthew T. Roe, MD, MHS; E. Magnus Ohman, MD; Eric D. Peterson, MD, MPH

Arch Intern Med. 2008;168(15):1692-1698.

Background  Patient medical records are important means of communication among health care providers. Limited evaluation has been performed of the quality of the medical records or its association with health care processes or outcomes.

Methods  We performed an empirical evaluation of the completeness of medical records from 607 randomly selected patients admitted with non–ST-segment elevation acute coronary syndromes (NSTE ACS) to 219 US hospitals in the CRUSADE National Quality Improvement Initiative. Composite medical records scores were summated and compared by hospital academic status and physician specialty. Correlations between medical records scores, use of evidence-based medicine (EBM), and in-hospital mortality were assessed.

Results  Medical records were frequently missing key elements, including cardiac history (23.6%), performance status (64.6%), differential diagnosis (57.8%), and planned use of EBM (44.0%). Evidence-based medicine was more often discussed in medical records from academic medical centers vs nonacademic medical centers (69.7% vs 51.7%) (P < .001) and from cardiologists vs noncardiologists (60.5% vs 48.1%, P = .003). Higher medical records quality scores were associated with greater use of EBM among the medical records quality cohort (P = .006), and a similar trend was observed in CRUSADE overall: adjusted odds ratio, 1.26 (95% confidence interval, 0.92-1.72) for high vs low medical records quality. Higher medical records quality scores were associated with lower in-hospital mortality: adjusted odds ratio, 0.79 (95% confidence interval, 0.65-0.97).

Conclusions  Medical records for patients with NSTE ACS often lack key elements of the history and physical examination. Patients treated at hospitals with better medical records quality have significantly lower mortality and may receive more EBM. The relationship between better medical charting and better medical care could lead to new ways to monitor and improve the quality of medical care.

Author Affiliations: Department of Medicine (Drs Dunlay and Kraschnewski), Division of Cardiology (Drs Alexander, Roe, Ohman, and Peterson), Duke University Medical Center, and Duke Clinical Research Institute (Drs Alexander, Melloni, Liang, Roe, Ohman, and Peterson), Durham, North Carolina; and Department of Emergency Medicine, University of Cincinnati School of Medicine, Cincinnati, Ohio (Dr Gibler).