主要诊断ICD-10编码在检索5种经蝶窦垂体术后31天内非计划再入院原因的真实性研究  

Investigation of the Validity of ICD-10 codes in Detecting Five Reasons for Unplanned Readmissions within 31 Days after Transsphenoidal Pituitary Surgery

作　　者：周婧雅[1] 王怡[1] 白雪[1] 张萌[1] 郭晓鹏 王子豪 幸兵[2] Zhou Jingya;Wang Yi;Bai Xue;Zhang Meng;Guo Xiaopeng;Wang Zihao;Xing Bing(Department of Medical Records and Collaborating Center for the WHO Family of International Classifications in China,Peking Union Medical College Hospital,Chinese Academy of Medical Sciences,Beijing,100730,China;不详)

机构地区：[1]北京协和医院病案科&世界卫生组织国际分类家族中国合作中心,北京市100730 [2]中国医学科学院北京协和医学与北京协和医院神经外科,北京市100730

出　　处：《中国病案》2022年第9期16-20,共5页Chinese Medical Record

基　　金：中央高校基本科研业务费专项资金资助(3332021017);中央高水平医院临床科研业务费资助(2022-PUMCH-A-085)。

摘　　要：目的研究住院病案首页主要诊断ICD-10编码在检索5种经蝶窦垂体术后31天内非计划再入院原因的真实性。方法从某三甲综合医院住院病案首页数据库提取2008年12月1日-2018年12月30日期间接受经蝶窦垂体手术且31天内再次入院的患者住院病案首页数据,以原始病案记录的再入院原因为依据,分别计算当主要诊断采用ICD-10单一编码和多个编码组合进行检索时,所反映的常见5种垂体术后出院31天再入院原因的敏感度、特异性、阳性预测值和阴性预测值,以评价经蝶窦垂体术后再入院患者主要诊断编码的真实性。结果当采用主要诊断单一编码对再入院原因进行检索时,术后鼻衄和术后颅内感染编码的敏感度最低,两者均为16.7%,95%CI分别为:0.9-63.5%,5.5-38.2%;脑脊液漏编码的敏感度最高为82.4%,95%CI:55.8-95.3%。当采用多个编码联合检索时,术后鼻衄从16.7%上升至83.3%,低钠血症从77.8%上升至100%,术后垂体功能减退从55.6%上升至77.8%,3种原因的编码敏感度大幅提高,术后颅内感染的编码敏感度虽亦有所提升,但仅为50%。除脑脊液鼻漏编码阳性预测值相对较低外,其他再入院原因编码无论在采用单一或多个编码时阳性预测值均高于90%。医师对主要诊断的错误选择和编码员编码错误是影响主要诊断编码反映真实再入院原因的主要问题来源。结论利用住院病案首页主要诊断单一编码检索5种常见经蝶窦垂体术后31天内非计划再入院原因的真实性有待提升,应积极在医师中开展正确主要诊断选择的培训,同时提升编码员正确编码术后并发症的能力。调整住院病案首页ICD-10编码检索方式,或可减少对垂体术后非计划再入院情况的遗漏。Objectives This study aims to investigate the validity of ICD-10 codes of primary diagnosis on the front pages of inpatient medical records in detecting common readmission reasons within 31 days after five types of transsphenoidal pituitary surgery(TSS).Methods This study retrieved the front-page data of patients who were readmitted to the hospital within 31 days after TSS from December 1,2008 to December 30,2018.Based on the reason for readmission summarized from original medical records,sensitivity,specificity,positive predictive value and negative predictive value of five major postoperative complications were calculated when the main diagnosis was retrieved by a single code and a combination of multiple codes,so as to evaluate the validity of the main diagnosis codes of readmission after TSS.Results When a single code was used for retrieving the reason of readmission,ICD-10 code for postoperative epistaxis and postoperative intracranial infection demonstrated the lowest sensitivity 16.7%for both;95%CI:0.9-63.5%and 95%CI:5.5-38.2%,respectively.ICD-10 codes for cerebrospinal fluid leakage had the highest sensitivity 82.4%;95%CI:55.8-95.3%.When multiple codes were applied,coding sensitivity for postoperative epistaxis(from 16.7%to 83.3%),hyponatraemia(from 77.8%to 100%)and postoperative hypopituitarism(from 55.6%to 77.8%)substantially improved.The sensitivity of postoperative intracranial infection code improved merely to 50.0%.Apart from a relatively low positive predictive value for cerebrospinal fluid leakage,coding for all other readmitted reasons had a PPV higher than 90%for both identification algorithms.Wrong selection of primary diagnoses by doctors and coding error from coders accounted for the main sources of inaccuracies on reasons of five readmission.Conclusions Single code on the medical record front pages is deficient in detecting the validity of five readmission reasons within 31 days after TSS.Interventions for enhancing principal diagnosis selection and coding ability for readmission reasons sho

关 键 词：住院病案首页 非计划再入院 经蝶窦垂体手术 ICD-10 真实性 

分 类 号：R651.13[医药卫生—外科学]