Valutazione della qualità ed appropriatezza delle codifica per Infarto Miocardico Acuto (IMA) sulle cartelle cliniche, Anno 2011.

Research output: Other contribution


[automatically translated] Introduction: The timeliness in performing percutaneous angioplasty on patients with diagnosis of AMI STEMI is crucial for the survival of the patient. In order to achieve a level of quality sufficient for coding of Acute Coronary Syndromes (ACS), able to correctly distinguish between IMA N-STEMI and STEMI, has been provided with DA of 2011 an update of the Guidelines for the coding of clinical information present in the Hospital Discharge Data sheet (SDO). Objective: To evaluate the quality of the SCA coding by comparing the information in the SDO and information content present in medical records for the various hospitals in Sicily, in 2011. Methods: As part of the analytical controls for the appropriateness, the Region has launched a survey on the quality of coding for AMI in-patient dispensing facilities. It draws prepared a sample check of some SDO in order to evaluate the coincidence between encoding of SDO and patient records. The ECG trace, control item has been examined by a blinded external expert to the structure investigated. the sensitivity and the specificity were measured to evaluate the capacity that has the SDO to correctly discriminate the cases of SCA, as well as to highlight the extent of any compile error in the encoding of diagnoses. Results: A total of 42 selected by supplying structures, were extracted a total of 840 medical records distributed equally among the different structures (20 for each structure). However, The control phase led to a total of 822 clinical records for which it has been drawn the required information about the characterization of the EPI, consequently reducing the sample size. The percentage of agreement between information contained in the SDO and the information derived from the examination of medical records varies from a minimum of 30% to a maximum of 100%. 45% of the structures involved in the control operations, the percentage of concordance was greater than or equal to 80%, while 50% lower percentages of correlation were found only in 7% of the involved structures. Moreover, the discrepancy found between SDO and medical records not always be the same type, leading in some cases to over-reporting of cases of AMI STEMI, in other cases to an under-notification. Conclusion: The quality of information derived from SDO would seem on the whole to ensure a reliable distinction between the three types of SCA. However, the high variability present in the series of regional structures, as well as the uneven distribution of missing cases, requires further analysis in order to investigate the causes that led to the poor results of the control process in place to be from the region.
Original languageItalian
Publication statusPublished - 2013

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