加拿大ACS-NSQIP结直肠手术编码的评价者间可靠性
Yingqi Xiong1, Richard T Spence2, Greg Hirsch2
1Nova Scotia Health Authority, Canada.
American journal of surgery
|June 29, 2024
概括
加拿大外科临床护士审查员 (SCNRs) 对结直肠切除的编码准确性显示出低可靠性. 这种不一致性显著影响了使用美国外科医生学院国家外科质量改进项目 (ACS-NSQIP) 计算器对患者结果的风险预测.
科学领域:
- 改善外科手术的质量
- 医疗信息学 医疗信息学
- 医学编码 医学编码
背景情况:
- 美国外科医生学院国家外科质量改善项目 (ACS-NSQIP) 依靠当前程序术语 (CPT) 代码进行风险调整计算.
- 准确的编码对于可靠的质量评估和手术结果中的风险预测至关重要.
研究的目的:
- 评估加拿大ACS-NSQIP外科临床护士审查员 (SCNRs) 之间编码结直肠切除的评审者间可靠性.
- 用ACS-NSQIP风险计算器评估编码变化对风险预测的影响.
主要方法:
- 加拿大的外科临床护士审查员 (SCNR) 编码了结直肠切除的模拟手术报告.
- 评估者之间的可靠性是使用百分比协议和自由边际卡帕相关性来评估的.
- 使用ACS-NSQIP风险计算器量化编码变化对预测风险的影响.
主要成果:
- 只有29.3%的SCNR回应,每个案例被分配3到6个不同的CPT代码.
- 百分比一致率从6.7%到62.3%不等,而kappa值显示了中等到高的不同意见.
- 由于编码的变化,ACS-NSQIP风险计算器显示了预测并发症风险 (0.2%-13.7%) 和死亡率 (0.2%-6.3%) 的绝对差异.
结论:
- 在加拿大SCNR中,在编码ACS-NSQIP结直肠程序时,评审者之间的可靠性较低.
- 这种编码不一致性显著影响了对患者结果的风险预测的准确性.
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