Dixon J, Sanderson C, Elliott P, Walls P, Jones J, Petticrew M
London School of Hygiene and Tropical Medicine, Health Services Research Unit.
J Public Health Med. 1998 Mar;20(1):63-9. doi: 10.1093/oxfordjournals.pubmed.a024721.
The aim of the study was to assess the reproducibility of clinical coding in two National Health Service hospitals within North West Thames region.
A retrospective audit was carried out, of clinical coding in hospital episode statistics, involving comparison of the codes assigned by local staff with those assigned by members of an external team unaware of the locally assigned codes. Where local and external coders disagreed, the records were reviewed for a third time by a further independent coder. The subjects were a random sample of 1607 non-maternity, non-psychiatric admissions occurring between 1991 and 1993, stratified for year and type of disease (asthma, diabetes, appendicitis, fractured femur and 'general'--a random selection of any diagnoses). The main outcome measures were the levels of exact agreement between local and external teams over codes for main diagnosis and procedure, and the level of approximate agreement (over the first three characters of the ICD-9 code for diagnosis and the letter and first two digits of the OPCS-4 code for procedure). For disagreements, the outcome measure was the level of agreement between the 'third' coder and the local and external coders.
For the main diagnosis in the 'general' group at hospital A, internal and external coders agreed exactly in 43 per cent of the admissions examined and agreed 'approximately' in 55 per cent (kappa = 0.54). For hospital B the corresponding figures were 60 per cent and 72 per cent (kappa = 0.72). Approximate agreement was higher for the specific diseases considered, particularly for asthma (A: 86 per cent; B: 91 per cent) and fractured femur (A: 84 per cent; B: 89 per cent). For the main procedure at hospital A, there was exact agreement for 58 per cent and approximate agreement for 70 per cent (kappa = 0.66). For hospital B, the corresponding figures were 76 per cent and 83 per cent (kappa = 0.80). In cases of disagreement over the first three digits of the ICD-9 code for main diagnosis, the third coder disagreed with both local and external coders in 53 per cent at hospital A and 38 per cent at hospital B. Agreement was slightly better for discharges in 1992-1993 than in 1991-1992.
The full clinical codes in NHS hospital episode statistics (HES) data should be treated with caution. The first three characters of ICD-9 codes for diagnoses and the OPCS-4 codes for procedures were more reliable. For some specific conditions such as asthma and fractured femur, reliability of the first three characters is much higher (for example, 86 per cent and 91 per cent for asthma in the two hospitals), but for the full codes can be worse. Secondary diagnoses or comorbidities may be significantly undercoded. A higher level of agreement in 1992-1993 than in 1991-1992 suggests that coding may be improving.
本研究旨在评估泰晤士河西北地区两家国民保健服务医院临床编码的可重复性。
进行了一项回顾性审计，涉及医院病历统计中的临床编码，将当地工作人员分配的编码与不知晓当地所分配编码的外部团队成员所分配的编码进行比较。当本地编码员和外部编码员意见不一致时，由另一位独立编码员对记录进行第三次审查。研究对象是1991年至1993年间1607例非产科、非精神科住院病例的随机样本，按年份和疾病类型（哮喘、糖尿病、阑尾炎、股骨骨折和“综合”——随机选取的任何诊断）分层。主要结局指标是本地和外部团队在主要诊断和手术编码上的完全一致水平，以及近似一致水平（针对诊断的ICD - 9编码的前三个字符和针对手术的OPCS - 4编码的字母及前两位数字）。对于存在分歧的情况，结局指标是“第三位”编码员与本地和外部编码员的一致水平。
对于医院A“综合”组的主要诊断，内部和外部编码员在所审查的住院病例中有43%完全一致，55%“近似”一致（kappa = 0.54）。对于医院B，相应数字分别为60%和72%（kappa = 0.72）。对于所考虑的特定疾病，近似一致率更高，尤其是哮喘（A：86%；B：91%）和股骨骨折（A：84%；B：89%）。对于医院A的主要手术，完全一致率为58%，近似一致率为70%（kappa = 0.66）。对于医院B，相应数字分别为76%和83%（kappa = 0.80）。在主要诊断的ICD - 9编码前三位数字存在分歧的情况下，第三位编码员在医院A与本地和外部编码员意见均不一致的情况占53%，在医院B占38%。1992 - 1993年出院病例的一致性略好于1991 - 1992年。
国民保健服务医院病历统计（HES）数据中的完整临床编码应谨慎对待。诊断的ICD - 9编码和手术的OPCS - 4编码的前三个字符更可靠。对于某些特定病症，如哮喘和股骨骨折，前三个字符的可靠性要高得多（例如，两家医院哮喘的可靠性分别为86%和91%），但对于完整编码可能较差。次要诊断或合并症可能编码严重不足。1992 - 1993年的一致水平高于1991 - 1992年，表明编码可能在改进。
