A cohort study on physician documentation and the accuracy of administrative data coding to improve passive surveillance of transient ischaemic attacks
A cohort study on physician documentation and the accuracy of administrative data coding to improve passive surveillance of transient ischaemic attacks
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DOI：
10.1136/bmjopen-2016-015234
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发表时间：
2017-06-01
期刊：
影响因子：
2.9
通讯作者：
Coutts, Shelagh B.
中科院分区：
文献类型：
--
作者：
Yu, Amy Y. X.;Quan, Hude;Coutts, Shelagh B.
背景行政卫生数据在卫生研究和疾病监测中是有价值的，但在急诊科（艾德）识别短暂性脑缺血发作（TIA）的敏感性低至中等。我们的目的是确定预测的编码准确性为TIA.Methods的研究人群是从两个正在进行的研究诊断TIA，轻微中风和中风模仿。艾德图表由中风神经科医师手动审查，以获得临床诊断、患者特征和医生文件的内容。将管理数据代码与图表裁定的诊断进行比较，以确定管理数据错误分类的病例。结果在417例患者（39.1% TIA、37.2%小中风和23.7%拟中风）中，有122例TIA诊断的裁定和管理数据代码之间存在不一致。大多数分歧（n=103/122，84.4%）来自于在管理数据编码中被错误分类为非TIA的裁定TIA病例。有78例（18.7%）病例记录为不确定诊断，73例（17.5%）病例未明确诊断。当最终诊断不确定或不存在时，图表裁定和管理数据编码之间不一致的相对风险为1.82（1.36，2.44），风险差异为18.5%。多变量Logistic回归分析证实了这种关联使用不同的情况下定义algorithm.Conclusions在疑似TIA和轻微中风患者提交给艾德，医生的文件是编码准确性的主导因素，支持的概念，医生是积极参与行政数据编码。预测改进图表文档的策略对编码准确性有积极影响。
Background Administrative health data are valuable in health research and disease surveillance, but have low to moderate sensitivity in identifying transient ischaemic attacks (TIA) in the emergency department (ED). We aimed to identify the predictors of coding accuracy for TIA.Methods The study population was obtained from two ongoing studies on the diagnosis of TIA, minor stroke and stroke mimic. ED charts were manually reviewed by a stroke neurologist to obtain the clinical diagnosis, patient characteristics and content of physician documentation. Administrative data codes were compared with the chart-adjudicated diagnosis to determine cases of misclassification by administrative data. Univariable regression was used to evaluate candidate predictors of disagreement, and the significant variables were tested in a multivariable model to obtain an adjusted estimate of effect.Results Among 417 patients (39.1% TIA, 37.2% minor stroke and 23.7% stroke mimics), there were 122 cases of disagreement between adjudications and administrative data codes for the diagnosis of TIA. The majority of disagreement (n=103/122, 84.4%) arose from adjudicated TIA cases that were misclassified as non-TIA in administrative data coding. There were 78 (18.7%) charts with documented uncertain diagnosis, and 73 (17.5%) charts had no definite diagnosis. The relative risk of disagreement between chart adjudication and administrative data coding when the final diagnosis was uncertain or absent was 1.82(1.36, 2.44) and the risk difference was 18.5%. Multivariable logistic regression analyses confirmed this association using different case definition algorithms.Conclusions In suspected patients with TIA and minor stroke presenting to the ED, physician documentation was the dominant factor in coding accuracy, supporting the concept that physicians are active participants in administrative data coding. Strategies to improve chart documentation are predicted to have a positive effect on coding accuracy.