Switching from System-Based to Problem-Based Charting Increases the Patient-Specific Expected Mortality Rate and Length of Stay on a Neurosurgery Service

INTRODUCTION: To date, limited research has focused on how charting styles can affect quality metrics in neurosurgery. METHODS: We performed a comparative interrupted time-series analysis at an urban, academic, level I trauma center. The intervention consisted of adjusting the charting style from system-based to problem-based charting on an inpatient neurosurgery service line and providing a one-hour educational session targeting improved documentation of three problems with high clinical relevance to neurosurgery. RESULTS: Among patients whose providers were exposed to the charting improvement intervention, there was a significant increase in the E-MR (p = 0.029). Average E-LOS also increased to a degree that approached significance (p = 0.085). In a multivariate model adjusting for elective status, length of stay, cost of admission, and hospital associated complications, the increases in both E-MR (p = 0.029) and E-LOS (p = 0.091) persisted. The switch from SBC to PBC resulted in noninferior rates of documentation (p>0.05) for the six most common complications not targeted as documentation opportunities during the educational intervention. Among patients in the reference group, whose providers did not receive the charting intervention, there was no significant change in either the E-MR (p = 0.198) or the E-LOS (p = 0.341), both of which slightly decreased over the course of the study period. CONCLUSIONS: Switching from SBC to specialty-focused PBC on a neurosurgery service line at an urban, academic, level I trauma center led to a statistically significant increase in the average patient-specific E-MR and a trend toward significant increase in the average patient-specific E-LOS. The study illustrates the degree to which a low-cost intervention on documentation patterns can impact neurosurgical risk-adjusted quality metrics.