Facilitating quality improvement in physician management of comorbid chronic disease in an urban minority practice.

Context: Increasing numbers of patients with multiple chronic conditions present in the primary care setting and pose a challenge to physicians who must cope with competing demands while adhering to clinical practice guidelines. Purpose: We tested a chart audit tool to assess how physicians are managing patients with multiple comorbidities in an inner-city family medicine practice serving minority patients. Methods: We developed an evidence-based comorbidity chart audit tool that captures the number of diagnosed, coexisting general medical conditions and adherence to key clinical practice guidelines for each condition. A randomized chart audit was undertaken, with one in every five charts selected, yielding a total of 314 patient charts. Findings: The majority of patients (59%) had >= 2 comorbid chronic conditions, and 32% had >= 3 comorbid chronic conditions. The highest overall adherence to guidelines was for chronic obstructive pulmonary disease (90%) and asthma (80%), followed by congestive heart failure (75%) and coronary artery disease (58%). For all other conditions, overall adherence to guidelines was <= 50%. Conclusions: The chart review tool identified inconsistencies in adherence to guidelines across multiple diagnosed conditions, suggesting the importance of adopting a patient-centered approach to management as well as prevention.