Study on the accuracy of official recording of nosological codes in an Italian regional hospital registry.
This paper describes an analysis of the quality of hospital discharge data stored in an Italian regional registry. Although limited in scope, this analysis sheds some light on the level of quality that users can expect in official health data and describes some factors which can influence such quality. Attention focuses on the accuracy with which official administrators code Diseases of Circulatory System (DCS) in a specified health district, using the discharge diagnosis formulated on the case-notes. Investigation of the data, a random sample of 993 medical records, shows a disturbing level of inaccuracy in the assignment of the primary diagnosis to the (DCS) group and sub-groups, especially when compared with other international experiences. Two factors, namely the type of hospital where official administrators routinely collect the data and the age of the in-patients, are found to significantly influence such inaccuracy. Explanations of these findings are suggested and proposals for the improved accuracy of hospital discharge data are presented.
Lovison
G
G
Bellini
P
P
D000367:Age Factors; D002318:Cardiovascular Diseases / Q000145:classification*; D007558:Italy; D008490:Medical Informatics; D008499:Medical Records / Q000592:standards*; D010351:Patient Discharge; D011786:Quality Control; D012042:Registries / Q000592:standards*; D012189:Retrospective Studies