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首页> 外文期刊>BMC Medical Informatics and Decision Making >Validity of registration of ICD codes and prescriptions in a research database in Swedish primary care: a cross-sectional study in Skaraborg primary care database
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Validity of registration of ICD codes and prescriptions in a research database in Swedish primary care: a cross-sectional study in Skaraborg primary care database

机译：ICD代码和处方在瑞典初级保健研究数据库中注册的有效性：在Skaraborg初级保健数据库中进行的横断面研究

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Background In recent years, several primary care databases recording information from computerized medical records have been established and used for quality assessment of medical care and research. However, to be useful for research purposes, the data generated routinely from every day practice require registration of high quality. In this study we aimed to investigate (i) the frequency and validity of ICD code and drug prescription registration in the new Skaraborg primary care database (SPCD) and (ii) to investigate the sources of variation in this registration. Methods SPCD contains anonymous electronic medical records (ProfDoc III) automatically retrieved from all 24 public health care centres (HCC) in Skaraborg, Sweden. The frequencies of ICD code registration for the selected diagnoses diabetes mellitus, hypertension and chronic cardiovascular disease and the relevant drug prescriptions in the time period between May 2002 and October 2003 were analysed. The validity of data registration in the SPCD was assessed in a random sample of 50 medical records from each HCC (n = 1200 records) using the medical record text as gold standard. The variance of ICD code registration was studied with multi-level logistic regression analysis and expressed as median odds ratio (MOR). Results For diabetes mellitus and hypertension ICD codes were registered in 80-90% of cases, while for congestive heart failure and ischemic heart disease ICD codes were registered more seldom (60-70%). Drug prescription registration was overall high (88%). A correlation between the frequency of ICD coded visits and the sensitivity of the ICD code registration was found for hypertension and congestive heart failure but not for diabetes or ischemic heart disease. The frequency of ICD code registration varied from 42 to 90% between HCCs, and the greatest variation was found at the physician level (MORPHYSICIAN = 4.2 and MORHCC = 2.3). Conclusions Since the frequency of ICD code registration varies between different diagnoses, each diagnosis must be separately validated. Improved frequency and quality of ICD code registration might be achieved by interventions directed towards the physicians where the greatest amount of variation was found.
机译：背景技术近年来，已经建立了一些记录来自计算机病历的信息的初级保健数据库，并将其用于医疗保健和研究的质量评估。但是，为了对研究有用，每天从日常实践中生成的数据都需要高质量的注册。在这项研究中，我们旨在调查（i）新的Skaraborg初级保健数据库（SPCD）中ICD代码和药物处方注册的频率和有效性，以及（ii）调查此注册中的变异来源。方法SPCD包含匿名电子病历（ProfDoc III），该病历自动从瑞典Skaraborg的所有24个公共卫生保健中心（HCC）检索。分析了2002年5月至2003年10月期间所选的诊断为糖尿病，高血压和慢性心血管疾病的ICD代码注册频率以及相关的药物处方。使用病历文本作为黄金标准，从每个HCC（n = 1200条记录）的50条病历的随机样本中评估了SPCD中数据注册的有效性。使用多级逻辑回归分析研究了ICD代码注册的方差，并表示为中位数优势比（MOR）。结果对于糖尿病和高血压，ICD代码在80-90％的病例中被注册，而对于充血性心力衰竭和缺血性心脏病，ICD代码很少被注册（60-70％）。药物处方注册总体较高（88％）。对于高血压和充血性心力衰竭，ICD编码访视的频率与ICD编码注册的敏感性之间存在相关性，而对于糖尿病或缺血性心脏病则没有相关性。在肝癌之间，ICD代码注册的频率从42％到90％不等，并且在医师级别上发现的变化最大（MOR PHYSICIAN = 4.2和MOR HCC = 2.3） 。结论由于ICD代码注册的频率在不同的诊断之间有所不同，因此每个诊断必须分别进行验证。 ICD代码注册的频率和质量提高可以通过针对医师的干预来实现，在这些医师中发现最大的变异。

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