The Completeness of Medical Records to Assess Quality of Hospital Care: The Case of Acute Myocardial Infarction in a District-level General Hospital in Iran

BACKGROUND: Quantifying the quality of care in high-cost and fatal conditions such as acute myocardial infarction (AMI) is a crucial step toward improving clinical outcomes in these patients. The main objective of this pilot study is to show whether abstraction of medical charts would be a useful method to systematically assess quality of care in patients hospitalized for AMI in a general hospital that has no interventional cardiac technology. METHODS: A general physician and a cardiologist working with Shahid Gholipour Hospital in Bukan, Northwest Iran, retrospectively abstracted medical records of all patients with verified diagnoses of myocardial infarction who were hospitalized between April 1, 2010 and March 31, 2011. The targeted outcome variables were risk-adjusted mortality and risk-adjusted length of hospital stay. Process quality indicators were selected from those developed by the National Quality Forum (NQF) of the United States. We reported completeness of selected variables used to build and calculate quality indicators in this study. RESULTS: For most variables, missing values were negligible. However, missing data on fields related to contraindications for prescribed medications were common. CONCLUSIONS: Medical chart abstractions provide useful first steps in assessing differences in the quality of hospital care for patients with AMI. Extension of our pilot study is highly recommended and may help trigger policy decisions to promote hospital quality in Iran