基于临床诊疗规范的胃肠间质瘤ICD-O编码质量研究

Coding Quality Research on Cases of Gastrointestinal Stromal Tumors Based on Clinical Treatment Standards

目的了解胃肠间质瘤的疾病编码现状,以提高编码准确率。方法于某院电子病案系统筛选2000年1月-2016年6月的胃肠间质瘤住院病例,收集临床诊断、病理及疾病编码信息。比较目前的编码结果和基于《中国胃肠间质瘤诊断治疗共识(2013年版)》标准的ICD-O编码结果,并分析编码错误的原因。结果 213例胃肠间质瘤中需修正疾病编码者达158例,占74.2%。其中,因编码库更新不及时的107例,占67.7%,因编码员编码标准不一致的40例,占25.3%,余者为未送检病理或病理报告信息不完整,占7.0%。结论胃肠间质瘤疾病编码准确率低,最主要原因是编码库更新不及时及编码标准不一致。通过积极查阅权威文献,与临床及病理医师讨论后确定统一标准,及时更新编码库,可提高编码准确率。

Objective To investigate the current situation of gastrointestinal stromal tumors （GIST）, so as to improve the accuracy. Methods To find out all cases with discharge diagnosis of GIST that were admitted during January, 2000 and June, 2016 by the electronic medical record system of a tertiary hospital. Information of clinical diagnosis, pathological report and disease coding were reviewed and collected. The current coding results were then compared with those using a new criteria based on ＂The consensus for diagnosis and treatment of gastrointestinal stromal tumors in China （2013 Edition）＂. Reasons of incorrect coding were sought and summarized. Results A total of 213 cases with GIST were included this study. And 158 cases （74.2%） were incorrectly coded. As to reasons of miscoding, up to 67. 7% were due to delayed updating of coding database, 25.3% due to inconsistent coding criteria, and the remaining 7.0% due to absent or incomplete pathological reports. Conclusions At present, the accuracy of ICD-O coding in GIST was low, and the main reasons were delayed updating of coding database and inconsistent coding criteria. The coding accuracy might be improved by reestablishing consistent coding criteria based on authoritative literature and muhidisciplinary export opinion, as well as timely updating of the coding database.