Polissar L, Feigl P, Lane W W, Glaefke G, Dahlberg S
J Natl Cancer Inst. 1984 May;72(5):1007-14.
The accuracy of data coded from the medical records of 985 patients from 22 major U.S. cancer centers was checked by recoding during 1978-81. The 29 items covered demographics, diagnosis, and therapy. Original codes were compared to recodes, and disagreements were classified as major or minor. The highest rate of major disagreements, 23%, was for stage of disease, followed by 10% for histology and 7% for site. Major disagreement rates for most other items were under 7%. Only 3% of a large sample of major disagreements involved justifiable differences in interpretation; the others were due to errors in the use of records. Major disagreement rates varied by a factor of 10 across sites, 4 across centers, and 2 across stage of disease. For several items the code "unknown" was overused and led to disagreements. A new procedure is presented for analysis of disagreement rates. The results from this procedure can guide training effort to improve coding accuracy.
1978年至1981年期间，通过重新编码对来自美国22家主要癌症中心的985名患者病历中编码的数据准确性进行了检查。这29个项目涵盖了人口统计学、诊断和治疗。将原始编码与重新编码进行比较，分歧被分为主要分歧或次要分歧。主要分歧率最高的是疾病分期，为23%，其次是组织学，为10%，部位为7%。大多数其他项目的主要分歧率低于7%。在大量主要分歧样本中，只有3%涉及合理的解释差异；其他分歧是由于记录使用中的错误。主要分歧率在不同地点相差10倍，在不同中心相差4倍，在疾病分期相差2倍。对于几个项目，代码“未知”被过度使用并导致了分歧。提出了一种分析分歧率的新程序。该程序的结果可以指导培训工作以提高编码准确性。
