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Poor Documentation Prevents Adequate Assessment of Quality Metrics in Colorectal Cancer

Department of Medicine, Division of Medical Oncology; Duke Comprehensive Cancer Center; Department of Medicine, Center for Clinical Health Policy Research; and Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, NC

Corresponding author: Amy P. Abernethy, MD, Duke University Medical Center, Box 3436, Durham, NC 27710; amy.abernethy{at}duke.edu.

Purpose: To describe the extent to which poor documentation hinders assessment of quality of care provided to patients with colorectal cancer (CRC) in the community and academic oncology settings.

Methods: This was a retrospective review of 499 medical records of patients obtained from 13 community and academic oncology practices in the southeastern United States. Data on diagnosis, TNM stage, any stage documentation, age, pathology report information, clinical care received, and care dates were abstracted. Descriptive statistics were used, and proportions of evaluable charts in which documented care conformed to accepted national metrics were calculated.

Results: Of the 499 patients, 43% were women, and 40% were men, whereas sex was not identified in 17%; 64% had colon cancer, and 21% had rectal cancer; 54% were white, and 17% were African American, whereas data on race or ethnicity were missing or unknown in 26%; mean age at diagnosis was 61 years (standard deviation, 14 years). Limited data availability hindered assessment of quality; of the 499 eligible patients, only 61 could be included in the full analysis. Only 86% of the 499 medical records confirmed diagnosis; 38% provided TNM stage (stage documentation improved to 73% when any clinical notation of stage was accepted); 71% documented age. Pathology reports were missing in 34% of medical records. When chemotherapy was initiated, more than 10% of medical records did not report dates of administration. When electronic medical records were used, reporting improved, but documentation problems persisted. In medical records containing data sufficient to evaluate conformance to CRC metrics, conformance was low (50% to 70%).

Conclusion: Assessment of quality of CRC care is impeded by the absence of sufficient documentation of data elements required to calculate performance.

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