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Published on: June 16, 2014
Variation in Documenting Diagnosable Chronic Kidney Disease in General Medical Practice: Implications for Quality
Alex Kitsos1, Gregory M Peterson1, Matthew D Jose1,2
11 University of Tasmania, Hobart, Tasmania, Australia.
Insights
Chronic kidney disease (CKD) is often not documented in Australian general practice records. When recorded, CKD diagnosis uses varied terminology, impacting data quality for research and audits.
Area of Science:
- Medical Informatics
- Public Health
- General Practice
Background:
- Chronic kidney disease (CKD) is a growing public health concern in Australia.
- Limited data exists on CKD prevalence within Australian general practice.
- Varied terminology used by general practitioners (GPs) may hinder accurate CKD diagnosis documentation.
Purpose of the Study:
- To investigate the variation in terminology used by GPs when recording a diagnosis of CKD.
- To assess the documentation rates of CKD in Australian general practice.
Main Methods:
- Analysis of de-identified Australian general practice patient data (2013-2016).
- Inclusion of data from 329 general practices.
- Manual searches of coded and free-text medical records.
Main Results:
- Only 23.2% of patients with pathology evidence of CKD had a documented diagnosis.
- 2090 unique terms were used by GPs to document CKD.
- Commonly used terms were from standard software 'pick-list' options (84% of use).
Conclusions:
- CKD diagnosis is frequently undocumented or variably recorded in general practice.
- Flexible documentation may compromise data quality for clinical audit and research.
- Standardized terminology could improve CKD data accuracy in primary care.
Background:
National health surveys indicate that chronic kidney disease (CKD) is an increasingly prevalent condition in Australia, placing a significant burden on the health budget and on the affected individuals themselves. Yet, there are relatively limited data on the prevalence of CKD within Australian general practice patients. In part, this could be due to variation in the terminology used by general practitioners (GPs) to identify and document a diagnosis of CKD. This project sought to investigate the variation in terms used when recording a diagnosis of CKD in general practice.
Methods:
A search of routinely collected de-identified Australian general practice patient data (NPS MedicineWise MedicineInsight from January 1, 2013, to June 1, 2016; collected from 329 general practices) was conducted to determine the terms used. Manual searches were conducted on coded and on "free-text" or narrative information in the medical history, reason for encounter, and reason for prescription data fields.
Results:
From this data set, 61 102 patients were potentially diagnosable with CKD on the basis of pathology results, but only 14 172 (23.2%) of these had a term representing CKD in their electronic record. Younger patients with pathology evidence of CKD were more likely to have documented CKD compared with older patients. There were a total of 2090 unique recorded documentation terms used by the GPs for CKD. The most commonly used terms tended to be those included as "pick-list" options within the various general practice software packages' standard "classifications," accounting for 84% of use.
Conclusions:
A diagnosis of CKD was often not documented and, when recorded, it was in a variety of ways. While recording CKD with various terms and in free-text fields may allow GPs to flexibly document disease qualifiers and enter patient specific information, it might inadvertently decrease the quality of data collected from general practice records for clinical audit or research purposes.
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