Awad Mahmoud I, Shuman Andrew G, Montero Pablo H, Palmer Frank L, Shah Jatin P, Patel Snehal G
Department of Surgery, Head and Neck Service, Memorial Sloan-Kettering Cancer Center, New York, New York.
Head Neck. 2015 Jun;37(6):851-61. doi: 10.1002/hed.23682. Epub 2014 Jun 27.
The purpose of this study was to describe and compare how postoperative complications after oral cavity squamous cell carcinoma (SCC) surgery are reported in medical records, institutional billing claims, and national clinical registries.
The medical records of 355 previously untreated patients who underwent surgery for oral cavity SCC at our institution were retrospectively reviewed for postoperative complications. Information was compared with claims and National Surgical Quality Improvement Program (NSQIP) data.
We identified 219 patients (62%) experiencing 544 complications (10% major). Billing claims identified 29% of these patients, 36% of overall complications, and 98% of major complications. Of overlapping patients, NSQIP identified 27% of patients, 33% of overall complications, and 100% of major complications noted on chart abstraction.
The incidence of minor postoperative complications after oral cavity SCC surgery is relatively high. Both claims data and NSQIP accurately recorded major complications, but were suboptimal compared to chart abstraction in capturing minor complications.
本研究的目的是描述和比较口腔鳞状细胞癌(SCC)手术后的术后并发症在医疗记录、机构计费索赔和国家临床登记中的报告方式。
回顾性审查了我院355例未经治疗的口腔SCC手术患者的医疗记录,以了解术后并发症情况。将信息与索赔数据和国家外科质量改进计划(NSQIP)数据进行比较。
我们确定了219例(62%)患者发生了544例并发症(10%为严重并发症)。计费索赔识别出了这些患者中的29%、所有并发症的36%以及严重并发症的98%。在重叠患者中,NSQIP识别出了27%的患者、所有并发症的33%以及图表摘要中记录的严重并发症的100%。
口腔SCC手术后轻微术后并发症的发生率相对较高。索赔数据和NSQIP均准确记录了严重并发症,但在捕捉轻微并发症方面与图表摘要相比并不理想。