Richaud-Eyraud E, Ellini A, Clément M-C, Menu A, Dubois J
Agence technique de l'information sur l'hospitalisation (ATIH), 13, rue Moreau, 75012 Paris, France; Université Paris-Est Créteil Val de Marne, 61, avenue du Général-de Gaulle, 94010 Créteil cedex, France.
Agence technique de l'information sur l'hospitalisation (ATIH), 13, rue Moreau, 75012 Paris, France.
Rev Epidemiol Sante Publique. 2019 Sep;67(5):337-344. doi: 10.1016/j.respe.2019.05.007. Epub 2019 Jun 14.
Based on the observation of the misuse of ICD-10 to code the diagnoses in the RIM-P (lack of completeness, conformity and diversity), the Technical Agency for information on Hospital Care (ATIH), which provides tools for collecting medical information, conducted two actions in 2016. First, a chapter devoted to the instructions of coding has been written in the methodological guide of production of the RIM-P, second, a variable "type psy" was added to the ICD-10 nomenclature's file framing ICD-10 coding in the RIM-P. The purpose of this study is to describe the quality of diagnosis coding using ICD-10 in the RIM-P in 2015 and 2016.
The quality of diagnosis coding using ICD-10 in the summaries of activity of the RIM-P national databases was described in 2015 and 2016. The study focused on the completeness, the conformity and the diversity of coding.
Between 2015 and 2016, the percentage of summaries without primary diagnosis ("DP") decreased slightly for full-time (5.2% vs. 3.8%), part-time (6.3% vs. 4.9%) inpatient stays and outpatient care (9.9% vs. 8.9%). ICD-10 codes used to code DP or associated diagnosis ("DA"), while prohibited, mainly belong to Chapter V Mental and behavioral disorders. Per year, only one-third of the summaries and one-half of patients had two or more ICD-10 codes reported for inpatient stays (one-fifth of the summaries and one-fourth of the patients for outpatient care). In addition, per year and per facility, the average number of distinct ICD-10 codes used to fill "DP" or "DA" was approximately half as important in part-time hospitalization, as in full-time hospitalization or for outpatient care. Moreover, 90% of the health facilities used<550 distinct ICD-10 codes in full-time inpatient stays,<270 in part-time inpatient stays and<950 for outpatient care to code the "DP" or the "DA". The diversity of ICD-10 codes used was low and similar between 2015 and 2016, especially to describe the socio-economic environment, resistance to treatment or non-compliance.
This study emphasizes the need for a collective effort to improve the diversity of the diagnoses' coding in the RIM-P.
基于对RIM-P中ICD-10诊断编码使用不当情况（缺乏完整性、一致性和多样性）的观察，负责提供医疗信息收集工具的医院护理信息技术机构（ATIH）在2016年采取了两项行动。第一，在RIM-P制作方法指南中编写了一章关于编码说明的内容；第二，在RIM-P中ICD-10编码的文件框架中，向ICD-10术语表文件添加了一个“type psy”变量。本研究的目的是描述2015年和2016年RIM-P中使用ICD-10进行诊断编码的质量。
描述2015年和2016年RIM-P国家数据库活动摘要中使用ICD-10进行诊断编码的质量。该研究重点关注编码的完整性、一致性和多样性。
2015年至2016年期间，全日制（5.2%对3.8%）、非全日制（6.3%对4.9%）住院患者以及门诊护理（9.9%对8.9%）中无主要诊断（“DP”）的摘要百分比略有下降。用于编码DP或相关诊断（“DA”）的ICD-10编码虽被禁止，但主要属于第五章精神和行为障碍。每年，只有三分之一的摘要和一半的患者在住院期间报告了两个或更多的ICD-10编码（门诊护理分别为五分之一的摘要和四分之一的患者）。此外，每年每个机构用于填写“DP”或“DA”的不同ICD-10编码的平均数量，在非全日制住院中约为全日制住院或门诊护理的一半。此外，90%的医疗机构在全日制住院中使用少于550个不同的ICD-10编码，非全日制住院中少于270个，门诊护理中少于950个来编码“DP”或“DA”。2015年至2016年期间使用的ICD-10编码的多样性较低且相似，尤其是在描述社会经济环境、对治疗的抵抗或不依从方面。
本研究强调需要共同努力提高RIM-P中诊断编码的多样性。
