创伤患者精神健康、酒精和药物状况的病历与 ICD-10-AM 编码之间的一致性水平。
Level of agreement between medical record and ICD-10-AM coding of mental health, alcohol and drug conditions in trauma patients.
机构信息
Monash University, Australia.
The Alfred Hospital, Australia.
出版信息
Health Inf Manag. 2019 Sep;48(3):127-134. doi: 10.1177/1833358318769482. Epub 2018 Apr 19.
BACKGROUND
Despite the reliance on administrative data in epidemiological studies, there is little information on the completeness of co-morbidities in administrative data coded from medical records.
OBJECTIVE
The aim of this study was to quantify the agreement between the International Classification of Diseases, Tenth Revision, Australian Modification (ICD-10-AM) administrative coding of mental health, drug and alcohol co-morbidities and medical records in a severely injured patient population.
METHOD
A random sample of patients ( = 500) captured by the Victorian State Trauma Registry and definitively managed at the state's adult major trauma services was selected for the study. Retrospective medical record review was conducted to collect data about documented co-morbidities. The agreement between ICD-10-AM data generated from routine hospital coding and medical record-based co-morbidities was determined using Cohen's and prevalence-adjusted bias-adjusted kappa (PABAK) statistics.
RESULTS
The percentage of agreement between the medical record and ICD-10-AM coding for mental health, drug and alcohol co-morbidities was 72.8%, and the PABAK showed moderate agreement (PABAK = 0.46; 95% confidence interval (CI): 0.37, 0.54). There was no difference in agreement between unintentional injury patients (PABAK = 0.52; 95% CI: 0.42, 0.62) compared with intentional injury patients (PABAK = 0.36, 95% CI: 0.23, 0.49), and no change in agreement for patients admitted before (PABAK = 0.40; 95% CI: 0.30, 0.50) and after the introduction of mandatory co-morbidity coding (PABAK = 0.46; 95% CI: 0.37, 0.54).
CONCLUSION
Despite documentation in the medical record, a large proportion of mental health, drug and alcohol conditions were not coded in ICD-10-AM. Acknowledgement of these limitations is needed when using ICD-10-AM coded co-morbidities in research studies and health policy development.
IMPLICATIONS
This work has implications for researchers of drug and alcohol abuse; mental health; accidents and injuries; workers' compensation; health workforce; health services; and policy decisions for healthcare, emergency services, insurance industry, national productivity and welfare costings reliant on those research outcomes.
背景
尽管在流行病学研究中依赖于行政数据，但关于从病历中编码的合并症在行政数据中的完整性的信息却很少。
目的
本研究旨在量化精神健康、药物和酒精合并症的国际疾病分类第十版澳大利亚修正版（ICD-10-AM）行政编码与严重受伤患者人群的病历之间的一致性。
方法
从维多利亚州创伤登记处捕获的患者随机样本（n=500）和州内成人主要创伤服务机构的明确管理的患者被选入该研究。对病历进行回顾性审查以收集有关记录的合并症的数据。使用 Cohen 的和调整后的偏倚一致性 kapp 统计量（PABAK）来确定从常规医院编码生成的 ICD-10-AM 数据与病历为基础的合并症之间的一致性。
结果
病历与 ICD-10-AM 编码之间在精神健康、药物和酒精合并症方面的一致性百分比为 72.8%，PABAK 显示出中等程度的一致性（PABAK=0.46；95%置信区间（CI）：0.37，0.54）。与非故意损伤患者相比（PABAK=0.52；95%CI：0.42，0.62），故意损伤患者之间的一致性没有差异（PABAK=0.36，95%CI：0.23，0.49），并且在强制性合并症编码引入之前（PABAK=0.40；95%CI：0.30，0.50）和之后（PABAK=0.46；95%CI：0.37，0.54），患者的一致性没有变化。
结论
尽管在病历中有记录，但很大一部分精神健康、药物和酒精疾病在 ICD-10-AM 中未被编码。在研究和制定卫生政策时使用 ICD-10-AM 编码的合并症时，需要认识到这些局限性。
意义
这项工作对药物和酒精滥用、心理健康、事故和伤害、工人赔偿、卫生劳动力、卫生服务以及依赖这些研究结果的医疗保健、紧急服务、保险行业、国家生产力和福利成本的政策决策的研究人员具有重要意义。
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