Department of Surgery, University of California Davis Medical Center, Sacramento, CA 95817, USA.
Med Care. 2012 Sep;50(9):792-800. doi: 10.1097/MLR.0b013e31825a8b69.
The Agency for Healthcare Research and Quality Patient Safety Indicator (PSI) 11 uses International Classification of Disease, 9th Clinical Modification diagnosis code 518.81 ("Acute respiratory failure")-but not the closely related alternative, 518.5 ("Pulmonary insufficiency after trauma and surgery")-to detect cases of postoperative respiratory failure. We sought to determine whether hospitals vary in the use of 518.81 versus 518.5 and whether such variation correlates with coder beliefs.
We conducted a cross-sectional analysis of administrative data from July 2009 through June 2010 for UHC (formerly University HealthSystem Consortium)-affiliated centers to assess the use of diagnosis codes 518.81 and 518.5 in PSI 11-eligible cases. We also surveyed coders at these centers to evaluate whether variation in the use of 518.81 versus 518.5 might be linked to coder beliefs. We asked survey respondents which diagnosis they would use for 2 ambiguous cases of postoperative pulmonary complications and how much they agreed with 6 statements about the coding process.
UHC-affiliated centers demonstrated wide variation in the use of 518.81 and 518.5, ranging from 0 to 26 cases and 0 to 56 cases/1000 PSI 11-eligible hospitalizations, respectively. Of 56 survey respondents, 64% chose 518.81 and 30% chose 518.5 for a clinical scenario involving postoperative respiratory failure, but these responses were not associated with actual coding of 518.81 or 518.5 at the center level. Sixty-two percent of respondents agreed that they are constrained by the words that physicians use. Their self-reported likelihood of querying physicians to clarify the diagnosis was significantly associated with coding of 518.5 at the center level.
The extent to which diagnosis code 518.81 is used relative to 518.5 varies considerably across centers, based on local coding practice, the specific wording of physician documentation, and coder-physician communication. To standardize the coding of postoperative respiratory failure, the 518.81 and 518.5 codes have recently been revised to make the available options clearer and mutually exclusive, which may improve the capacity of PSI 11 to discriminate true differences in quality of care.
医疗保健研究和质量机构患者安全指标 (PSI) 11 使用国际疾病分类，第 9 临床修订版诊断代码 518.81（“急性呼吸衰竭”）-但不使用密切相关的替代方法 518.5（“创伤和手术后肺功能不全”）-来检测术后呼吸衰竭病例。我们试图确定医院在使用 518.81 与 518.5 方面是否存在差异，以及这种差异是否与编码员的信念相关。
我们对 2009 年 7 月至 2010 年 6 月期间 UHC（前身为大学卫生系统联盟）附属中心的行政数据进行了横断面分析，以评估 PSI 11 合格病例中诊断代码 518.81 和 518.5 的使用情况。我们还调查了这些中心的编码员，以评估使用 518.81 与 518.5 的差异是否与编码员的信念有关。我们要求调查受访者在 2 个术后肺部并发症的模糊病例中使用哪种诊断，并对 6 个关于编码过程的陈述表示多大程度的同意。
UHC 附属中心在使用 518.81 和 518.5 方面存在很大差异，范围分别为 0 至 26 例和 0 至 56 例/1000 例 PSI 11 合格住院治疗。在 56 名调查受访者中，64%的人选择 518.81，30%的人选择 518.5 用于涉及术后呼吸衰竭的临床情况，但这些反应与中心层面的实际 518.81 或 518.5 编码无关。62%的受访者同意他们受到医生使用的词语的限制。他们自我报告的询问医生以澄清诊断的可能性与中心层面的 518.5 编码显著相关。
基于当地编码实践、医生记录的具体措辞以及编码员与医生之间的沟通，各个中心使用诊断代码 518.81 相对于 518.5 的程度差异很大。为了使术后呼吸衰竭的编码标准化，最近对 518.81 和 518.5 代码进行了修订，以使可用选项更加清晰且相互排斥，这可能会提高 PSI 11 区分护理质量真实差异的能力。
