Medical Directorate, Inselspital, University Hospital of Bern, Bern, Switzerland.
Direktion Medizin Insel Gruppe, Operatives Medizincontrolling Kodierung, University Hospital, Bern, CH-3010, Switzerland.
BMC Health Serv Res. 2019 Jan 9;19(1):23. doi: 10.1186/s12913-018-3858-3.
With few exceptions the International Statistical Classification of Diseases (ICD) codes for diagnoses and official coding guidelines do not distinguish pre-existing conditions from complications or comorbidities which occur during hospitalization. However, information on diagnosis timing is relevant with regard to the case's severity, resource consumption and quality of care. In this study we analyzed the diagnostic value and reliability of the present-on-admission (POA) indicator using routinely collected health data.
We included all inpatient cases of the department of medicine during 2016 with a diagnosis of deep vein thrombosis, decubitus ulcer or delirium. Swiss coding guidelines of 2016 and the definitions of the Swiss medical statistics of hospitals were analyzed to evaluate the potential to encode information on diagnosis timing. The diagnoses were revised by applying the information present-on-admission by a coding specialist and by a medical expert, serving as Gold Standard. The diagnostic value and reliability were evaluated.
The inter-rater reliability for POA of all diagnoses was 0.7133 (Cohen's kappa), but differed between diagnosis groups (0.558-0.7164). The rate of POA positive of the total applied by the coding specialist versus the expert was similar, but differed between diagnoses. In group "thrombosis" SEN was 0.95, SPE 0.75, PPV 0.97 and NPV 0.60, in group "decubitus ulcer" SEN 0.89, SPE 0.82, PPV 0.89 and NPV 0.82, in group "delirium" SEN 0.91, SPE 0.65, PPV 0.71 and NPV 0.88 For all diagnoses SEN 0.92, SPE 0.73, PPV 0.87, NPV 0.82, summing up the cases of all diagnosis groups.
Coding the POA indicator identified diagnoses which were pre-existent with insufficient reliability on individual patient's level. The overall fair to sufficient diagnostic quality is appropriate for screening and benchmarking performance on population level. As the medical statistics of hospitals carries no variable on pre-existing conditions, the novel approach to apply the POA indicator to diagnoses gives more information on quality of hospital care and complexity of cases. By preparing documentation for POA reporting diagnostic quality must be increased before implementation for risk-assessment or reimbursement on the individual patient's level.
除了少数例外情况外，国际疾病分类（ICD）的诊断代码和官方编码指南并没有将既往疾病与住院期间发生的并发症或合并症区分开来。然而，关于诊断时间的信息与病例的严重程度、资源消耗和护理质量有关。在这项研究中，我们使用常规收集的健康数据分析了入院时即存在（POA）指标的诊断价值和可靠性。
我们纳入了 2016 年内科所有住院患者的深静脉血栓形成、压疮或谵妄诊断。分析了 2016 年瑞士编码指南和瑞士医院医疗统计的定义，以评估编码诊断时间信息的潜力。通过应用编码专家和医学专家提供的入院时诊断信息对诊断进行了修订，作为金标准。评估了诊断价值和可靠性。
所有诊断的 POA 之间的观察者间可靠性为 0.7133（Cohen 的 kappa），但在诊断组之间有所不同（0.558-0.7164）。编码专家和专家应用的 POA 阳性率总相似，但诊断不同。在“血栓”组中，SEN 为 0.95，SPE 为 0.75，PPV 为 0.97，NPV 为 0.60，在“压疮”组中，SEN 为 0.89，SPE 为 0.82，PPV 为 0.89，NPV 为 0.82，在“谵妄”组中，SEN 为 0.91，SPE 为 0.65，PPV 为 0.71，NPV 为 0.88，对于所有诊断，SEN 为 0.92，SPE 为 0.73，PPV 为 0.87，NPV 为 0.82，总结了所有诊断组的病例。
编码 POA 指标可以识别既往存在的诊断，但在个体患者层面的可靠性不足。整体而言，在人群层面进行筛查和基准测试的诊断质量为良好至充分。由于医院医疗统计没有既往疾病的变量，因此将 POA 指标应用于诊断的新方法提供了更多关于医院护理质量和病例复杂性的信息。在实施个人患者风险评估或报销之前，必须提高 POA 报告的诊断质量，以准备文档。
