全科医学诊断术语和编码研制及其应用的实证研究

Development of General Practice Diagnostic Terminology and Coding and Empirical Study on Its Application

背景建立统一的全科医学诊断术语和编码集是提升我国社区卫生服务机构服务水平和推动全科医学体系建设的重要手段,但一直以来缺乏适合我国全科医学发展现状的规范化诊断术语和编码,导致全科医师的诊断不规范、不标准,严重阻碍了我国全科医学的发展。目的构建社区卫生服务全科医学诊断术语和编码集,并验证诊断术语和编码集的有效性,促进社区全科诊断标准化和规范化。方法通过文献学习和专家咨询法,结合社区常见健康问题谱和疾病谱,基于国际疾病分类(ICD)-10构建社区卫生服务适用的全科诊断术语和编码集;于2021年9月—2022年2月在深圳市两个行政区的259家社区健康服务中心试点运行所研制的全科诊断术语和编码集以进行实证研究,以社区健康服务信息系统后台诊断数据和以社区全科医师为样本的问卷调研数据为基本数据,分析试点实施情况,验证诊断术语和编码集的合理性和有效性。结果编制完成全科医学诊断术语和编码集,其中全科诊断分类41种,含标准化全科诊断术语和编码6629项。深圳市两区试点结果显示,规范化干预区域的诊断名称规范化构成比较非试点区高86.13%~95.38%;试点区该时段涉及的诊断名称同比下降96.60%,规范化干预使全科常用诊断大为聚焦,且跟社区疾病谱基本一致,社区常见疾病诊断归集度高。问卷调查结果显示,87.31%(227/260)的调查对象认为编码集对社区诊断规范化有促进作用,77.31%(201/260)的调查对象支持编码集的上线应用。结论本研究初步建立规范化和标准化的全科医学诊断术语和编码集,形成了社区全科诊断术语字典,解决数据分析时一义多词的难题,同时兼顾上下转诊和医保对接,有效提高了社区诊疗效率和规范化水平,对基层卫生事业发展产生积极推动作用。

Background Establishing a unified set of diagnostic terms and codes for general practice is an important means to improve the service level of community health service institutions and promote the construction of general practice system in China.Establishing a unified set of diagnostic terms and codes of general practice is an important way to improve the service level of community health service institutions and the construction of general practice system in China.However,there has been a lack of standardized diagnostic terms and codes suitable for the development situation of general practice in China,leading to non-standard diagnosis of general practitioners,which has seriously hindered the development of general practice in China.Objective To construct a set of diagnostic terms and codes for general practice in community health care service,and validate its efficiency,so as to promote the standardization of community general practice diagnosis.Methods A set of diagnostic terms and codes for general practice suitable for community health care service was constructed based on ICD-10 by using literature research and expert consultation,combined with the spectrum of common health problems and diseases in the community,and piloted in 259 community health service centers in two administrative districts of Shenzhen from September 2021 to February 2022 to conduct an empirical study.The pilot implementation was analyzed to verify the rationality and validity of the diagnostic terms and codes set by using the background diagnostic data of the community health service information system and questionnaire study with a sample of community general practitioners as the basic data.Results A set of diagnostic terms and codes for general practice was completed,including 41 general practice diagnostic categories,involving 6629 standardized diagnostic terms and codes for general practice.The pilot results of the two districts in Shenzhen indicate that the composition of standardized diagnostic names in the standardized intervention areas was 86.13% to 95.38% higher than the nonpilot areas.The number of diagnostic names involved in this period in the pilot area decreased by 96.60%year-on-year.The standardized intervention resulted in a significant focus on common diagnoses in general practice,which is basically consistent with the disease spectrum in the community,with a high degree of clustering of common disease diagnoses in the community.The results of the questionnaire survey showed that 87.31%(227/260)of the survey respondents believed that the code set can promote the standardization of community diagnosis,and 77.31%(201/260)of the respondents supported the online application of the code set.Conclusion The research has preliminarily established a standardized set of diagnostic terms and codes for general practice,forming a community general practice diagnostic term dictionary to solve the problem of polysemy in data analysis,while taking into account upward and downward referrals and medical insurance dockin,which has effectively improved the efficiency and standardization of community diagnosis and treatment,and played a positive role in promoting the development of primary health services.