Uddin D E, Martin P A
Wright State University-Miami Valley College of Nursing and Health, Dayton, OH 45435, USA.
Comput Nurs. 1997 Mar-Apr;15(2 Suppl):S38-42.
Development of consistent health care information has been hampered by the lack of a core data set that contains clinical information. The Uniform Hospital Discharge Set was developed to record individual discharge profiles derived from hospital billing systems. Using that information, some states developed data repositories. Government and health insurers maintain databases of claims paid. The data are not consistent, not readily available, may not contain all encounters, and are financial, not clinical. Wide variance in number of procedures in different geographic regions, variability in mortality rates, and variance in expenditures for particular conditions have been identified from those databases. However, they contain little information to assess the 'best' clinical practices regarding patient outcome. We describe specific limitations of current data sets and how health services research, outcomes research, and policy research, could be improved by a core data set, as well as recommendations about a core data set.
缺乏包含临床信息的核心数据集阻碍了一致的医疗保健信息的发展。统一医院出院数据集的开发是为了记录从医院计费系统中获取的个人出院概况。利用这些信息，一些州建立了数据存储库。政府和健康保险公司维护已支付索赔的数据库。这些数据不一致、不易获取，可能不包含所有诊疗情况，而且是财务数据而非临床数据。从这些数据库中已发现不同地理区域的手术数量差异很大、死亡率存在变异性以及特定病症的支出存在差异。然而，它们几乎没有信息可用于评估关于患者预后的“最佳”临床实践。我们描述了当前数据集的具体局限性，以及核心数据集如何能够改善卫生服务研究、结局研究和政策研究，同时还给出了关于核心数据集的建议。
