Structured Implicit Review of the Medical Record

A Method for Measuring the Quality of Inhospital Medical Care and a Summary of Quality Changes Following Implementation of the Medicare Prospective Payment System

by Lisa V. Rubenstein, Katherine L. Kahn, Ellen Harrison, Marjorie J. Sherwood, William H. Rogers, Robert H. Brook

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To measure the quality of medical care before and after implementation of the Prospective Payment System (PPS) by Medicare, the authors developed methods for both implicit and explicit review of the medical record. Explicit review relies upon measurement of the extent to which care accords with previously specified criteria; implicit review depends upon a practitioner's expert opinion to develop a quality rating. The authors devised a structured method for implicit review, requiring physicians to analyze specified parts of the medical record and to assess their quality using a rating scale. The authors determined the performance characteristics of structured implicit review by evaluating interitem and interrater reliability. Despite the limitations in reliability of the structured implicit review method, they found that very poor quality of care was associated with increased death rates 30 days after admission. When they evaluated the quality of care before and after PPS, they found that the quality of medical care improved between 1981-1982 and 1985-1986. Thus, except for discharge planning processes, the quality of hospital care has continued to improve for Medicare patients.

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