江苏省基于HIS系统的心脑血管事件漏报调查  

Investigation for hospital information system-based underreporting of cardiovascular events in Jiangsu Province

作　　者：覃玉[1] 章剑[2] 顾晓平 苏健[1] 陈路路 陶然[1] 周金意[1] 颜流霞[4] 陈晓荣[4] QIN Yu;ZHANG Jian;GU Xiao-ping;SU Jian;CHEN Lu-lu;TAO Ran;ZHOU Jin-yi;YAN Liu-xia;CHEN Xiao-rong(Jiangsu Provincial Center for Disease Control and Prevention,Jiangsu Nanjing210009,China;不详)

机构地区：[1]江苏省疾病预防控制中心,江苏南京210009 [2]江阴市疾病预防控制中心 [3]盐城市大丰区疾病预防控制中心 [4]中国疾病预防控制中心慢性非传染性疾病预防控制中心

出　　处：《江苏预防医学》2021年第3期275-277,282,共4页Jiangsu Journal of Preventive Medicine

基　　金：国家重点研发计划课题“心脑血管疾病流行病学监测大数据采集、处理、分析技术及应用研究”(2018YFC1311703)。

摘　　要：目的掌握江苏省医院心脑血管事件报告漏报情况,为制定提高病例报告准确率措施提供依据。方法从无锡江阴市和盐城大丰区2家医院的医院信息系统(HIS系统),提取2015年、2017年和2019年3个年份10月份所有急性心肌梗死和脑卒中住院患者名单,与同时间段已上报国家监测系统的名单进行匹配,对未上报的个案,通过查询相关住院信息判断是否为漏报个案,计算漏报率。并分析江阴市人民医院漏报个案情况。结果 2所医院急性心肌梗死应报110例,漏报9例,漏报率为8.2%;应报脑卒中1 491例,漏报36例,漏报率为2.4%。从江阴市人民医院漏报个案诊断位次来看,8例漏报的急性心肌梗死患者,1例为第2诊断;27例漏报的脑卒中患者,9例为第2诊断。结论医院急性心肌梗死和脑卒中存在一定漏报,漏报原因可能与诊断位次等有关。应统一规范报病流程,减少漏报的发生。Objective To analyze underreporting of cardiovascular events in hospitals in Jiangsu province;to provide evidence for improving the accuracy of case report.Methods List of inpatients of acute myocardial infarction(AMI)and stroke in Oct.of 2015,2017 and 2019 were collected from the hospital information system(HIS)in two hospitals of Jiangyin and Yancheng Dafeng,which matched with the reporting cases from the National Surveillance System in the same period.For those not reported to the system,the underreporting cases were determined by checking related inpatient medical records.The underreporting rate was calculated and underreported case data from Jiangyin People′s Hospital were analyzed.Results There were 9 out of 110 AMI cases were underreported with a rate of 8.2%,and 36 out of 1 491 stroke cases were underreported with a rate of 2.4%.With respect of diagnostic orders of underreporting cases from Jiangyin People′s Hospital,1 out of 8 AMI cases and 9 out of 27 stroke cases were diagnosed at the second order.Conclusion There are underreported cases of AMI and stroke in hospitals.The diagnostic orders may be one of the reasons for the underreporting.The reporting process should be standardized to reduce underreporting.

关 键 词：急性心肌梗死 脑卒中 漏报 HIS系统 

分 类 号：R543[医药卫生—心血管疾病]