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Improving the accuracy of HES comorbidity codes by better documentation in surgical admission proforma
Ahmad Navid1, Shahin Hajibandeh2, Jayarama Mohan3
1General Surgery Registrar in the Department of General Surgery, Pilgrim Hospital, Boston, Lincolnshire.
Insights
Improving medical record documentation significantly enhances the accuracy of Hospital Episode Statistics (HES) data for comorbidities in general surgery patients. Better clerking proforma documentation boosts HES code accuracy and reliability.
Area of Science:
- Medical Informatics
- Health Services Research
- Clinical Auditing
Background:
- Poor documentation in medical notes compromises the quality of source data for medical coding.
- This can lead to inaccurate coding of patient comorbidities.
- The accuracy of Hospital Episode Statistics (HES) data for comorbidities is a critical concern.
Purpose of the Study:
- To determine the accuracy of HES data for comorbidities in general surgical patients.
- To assess if improved documentation in admission clerking proforma enhances comorbidity coding accuracy.
- To evaluate the impact of enhanced documentation on HES code sensitivity, specificity, and predictive values.
Main Methods:
- A clinical audit was performed to evaluate HES code accuracy for comorbidities before and after implementing improved documentation.
- Key comorbidities assessed included hypertension, ischemic heart disease, diabetes, asthma, COPD, cerebrovascular disease, CKD, and hypercholesterolemia.
- Medical notes served as the reference standard, with a target standard of 98% for accuracy measures.
Main Results:
- Initial HES code accuracy was suboptimal (90.5%, kappa=0.599), with low sensitivity (47.71%) and negative predictive value (89.60%).
- HES codes demonstrated 100% specificity and positive predictive value.
- Post-intervention, accuracy (99.67%, kappa=0.985), sensitivity (97.4%), and negative predictive value (99.62%) significantly improved (P<0.0001).
Conclusions:
- While HES codes are reliable for confirming the presence of comorbidities, their accuracy in ruling out conditions is suboptimal.
- Enhanced documentation in clerking proforma substantially improves HES code accuracy and their ability to rule out comorbidities.
- Improving clinician knowledge and accountability regarding comorbidity documentation is essential.
Background:
Poor documentation in medical notes can affect the quality of the source document for coding which can lead to inaccurate coding. This study aimed to determine the accuracy of Hospital Episode Statistics (HES) data for comorbidities and to establish whether better documentation in admission clerking proforma can improve the accuracy of codes for comorbidities in general surgical patients.
Methods:
A clinical audit was conducted to assess the accuracy, sensitivity, specificity, positive predictive value and negative predictive value of HES codes for comorbidities in general surgical patients before and after implementing better documentation in admission clerking proforma. The following comorbidities were included: hypertension, ischaemic heart disease, diabetes, asthma, chronic obstructive pulmonary disease, cerebrovascular disease, chronic kidney disease and hypercholesterolaemia. Medical notes were used as reference standard and a target standard of 98% was determined for the above measures.
Results:
Overall, on the initial audit, HES codes had substandard accuracy (90.5%, kappa = 0.599), sensitivity (47.71%, 95% confidence interval 38.05-57.49%) and negative predictive value (89.60%, 95% confidence interval 86.73-92.03%). HES codes for comorbidities were 100% specific with positive predictive value of 100%. Implementing better documentation in the admission clerking proforma improved the accuracy (99.67%, kappa = 0.985), sensitivity (97.4%, 95% confidence interval 90.93-99.68%) and negative predictive value (99.62%, 95% confidence interval 98.63-99.95%) significantly from the baseline (P<0.0001).
Conclusions:
Although HES codes can confidently predict the actual presence of the comorbidities, they have substandard accuracy and ability to rule out the presence of the comorbidities. Better documentation in clerking proforma can improve the accuracy and 'ruling out' ability of the HES codes. This can be achieved by improving knowledge and accountability of clinicians about documenting comorbidities.
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