Examining the reliability of ICD-10 discharge coding in Red Cross War Memorial Children's Hospital administrative database
Examining the reliability of ICD-10 discharge coding in Red Cross War Memorial Children's Hospital administrative database
复制标题
DOI：
10.7196/samj.2021.v111i2.14686
复制
发表时间：
2021-02-01
期刊：
影响因子：
--
通讯作者：
Buys, H
中科院分区：
文献类型：
--
作者：
Daniels, A;Muloiwa, R;Buys, H
背景。来自医院管理数据库的出院诊断数据通常用于与各种重要应用程序相关的决策。其中可能包括资源分配、保健质量评估、临床研究和保健政策的制定。准确编码和可靠捕获的患者出院数据对任何医院和卫生系统的有效运作至关重要。回顾性检验红十字战争纪念儿童医院（RCWMCH）初级和二级出院诊断管理数据库中国际疾病分类第10版（ICD-10）出院编码的可靠性，并提出改进建议。本研究是对2013年8月1日至2014年9月1日期间在RCWMCH短期住院和普通儿科病房住院的450名患者进行回顾性文件夹审查。首席研究员（PI）完成了每次入院的ICD-10出院编码，并将其与Clinicom （Siemens Medical Solutions, Germany）健康信息系统中捕获的每位患者的相应入院数据进行了比较。对4字和3字ICD-10编码的特异性进行了一致性比较。在最初的450个随机选择的文件夹中，在文件夹审查过程中分析了396个（88%）。PI文件夹检查编码的总诊断（原发性诊断加继发性诊断）中位数为3，分布为110（四分位数间距（IQR）为24）。Clinicom编码的总诊断中位数为1，分布为13 （IQR 11）。初步诊断编码对4个字符的符合率为26.3%，对3个字符的符合率为34.3%。4个特征的二次诊断符合率为14.9%，3个特征的二次诊断符合率为27.7%。RCWMCH的ICD-10行政数据可靠性较差。雇用专门和/或训练有素的编码人员方面的不足可能是造成这一问题的重要原因，应予以解决。
Background. Discharge diagnostic data from hospital administrative databases are often used to inform decisions relating to a variety of vital applications. These may include the allocation of resources, quality-of-care assessments, clinical research and formulation of healthcare policy. Accurately coded and reliably captured patient discharge data are of paramount importance for any hospital and health system to function efficiently.Objectives. To retrospectively examine the reliability of the International Classification of Diseases version 10 (ICD-10) discharge coding in Red Cross War Memorial Children's Hospital (RCWMCH)'s administrative database for primary and secondary discharge diagnoses, and to formulate recommendations for improvement to the current system.Methods. This study was a retrospective folder review of 450 patient admissions to the short-stay and general paediatric wards at RCWMCH between 1 August 2013 and 1 September 2014. The principal investigator (PI) completed ICD-10 discharge coding for each admission and compared it with the corresponding admission data captured for each patient in the Clinicom (Siemens Medical Solutions, Germany) health information system. Agreement comparison was done to 4and 3-character ICD-10 code specificity.Results. Of the initial 450 randomly selected folders, 396 (88%) were analysed during the folder review process. The median number of total diagnoses (primary diagnosis plus secondary diagnoses) coded by the PI folder review was 3, with a distribution of 1 10 (interquartile range (IQR) 2 4). The median number of total diagnoses coded in Clinicom was 1, with a distribution of 1 3 (IQR 1 1). Agreement of primary diagnosis coding to 4 characters was 26.3%, with slight improvement to 34.3% when assessed to 3 characters. Agreement of secondary diagnoses to 4 characters was 14.9%, and 27.7% when assessed to 3 characters.Conclusions. Reliability of administrative ICD-10 discharge data from RCWMCH is poor. Inadequacies regarding the employment of dedicated and/or adequately trained coding personnel may significantly contribute to the problem and should be addressed.