Mosbech J, Jørgensen J, Madsen M, Rostgaard K, Thornberg K, Poulsen T D
Sundhedsstyrelsen, København.
Ugeskr Laeger. 1995 Jun 26;157(26):3741-5.
The Danish National Patient Register, which includes information on all patients admitted to hospitals, has been evaluated as concerns the quality of the data included. The material examined consisted of a representative sample of 1094 patients from departments all over the country (gynaecology and obstetrics, medicine, surgery and paediatrics). Recoding of data, clinical as well as administrative, based on copies of the case records from the hospitals was carried out by two clinically working physicians (registrars). For the administrative data e.g. length of stay, satisfactory concordance was found. The validity of clinical information depended on clinical speciality and degree of diagnostic specificity. Based on the international classification the agreement on the three digit diagnostic level was better than on the five digit diagnostic level. For surgery the agreement was better than for medicine. The agreement between the diagnostic information (primary diagnosis) and the recoder in choosing primary diagnosis varied from 66-83 percent on the five digit level and between 73-89 percent on the three digit diagnostic level. If cases where the diagnosis in the registry could be regarded as an acceptable alternative were included, the agreement between the registry and recoding was 75-90%. In a subsample of the material double coding by the two coders was carried out and it was remarkable that, taken as a whole, the degree of agreement between the two coders was of the same size as between recoder and the registry. It is anticipated, however, that introduction of ICD-10 with more clear-cut rules for choice of primary diagnosis in morbidity coding will contribute to better validity and consequently improved hospital statistics.
丹麦国家患者登记册包含了所有住院患者的信息，该登记册就其所包含数据的质量进行了评估。所检查的材料包括来自全国各科室（妇产科、内科、外科和儿科）的1094名患者的代表性样本。两名临床在职医生（住院医生）根据医院病历副本对临床和行政数据进行了重新编码。对于行政数据，如住院时间，发现了令人满意的一致性。临床信息的有效性取决于临床专业和诊断特异性程度。根据国际分类，三位数诊断水平的一致性优于五位数诊断水平。外科手术的一致性优于内科。诊断信息（主要诊断）与重新编码者在选择主要诊断方面的一致性在五位数水平上为66% - 83%，在三位数诊断水平上为73% - 89%。如果将登记册中诊断可被视为可接受替代方案的病例包括在内，登记册与重新编码之间的一致性为75% - 90%。在材料的一个子样本中，由两名编码员进行了双重编码，值得注意的是，总体而言，两名编码员之间的一致程度与重新编码者和登记册之间的一致程度相同。然而，可以预期，在发病率编码中引入具有更明确主要诊断选择规则的ICD - 10将有助于提高有效性，从而改善医院统计数据。
