Examining the reliability of discharge ICD coding in the Red Cross War Memorial Children's Hospital administrative database

dc.contributor.advisorBuys, Heloise
dc.contributor.advisorMyer, Landon
dc.contributor.authorDaniels, Adriaan
dc.date.accessioned2019-02-26T09:12:39Z
dc.date.available2019-02-26T09:12:39Z
dc.date.issued2018
dc.date.updated2019-02-26T08:15:00Z
dc.description.abstractBackground: Discharge diagnostic data from hospital administrative databases are often used to inform decisions relating to a variety of vital applications. These may include the allocation of resources, quality of care assessments, clinical research and for the formulation of healthcare policy to name a few. Having accurately coded and reliably captured discharge data for patients is of paramount importance for any hospital and health system to function efficiently. Objectives: 1. Retrospectively examine the reliability of the ICD discharge coding in the Red Cross War Memorial Children’s Hospital (RCWMCH) administrative database for primary and secondary discharge diagnoses. 2. Formulate recommendations for improvement to the current system. Methods: This study was a retrospective folder review of 450 patient admissions to the short stay and general paediatric wards at the RCWMCH between 1 August 2013 and 1 September 2014. International Classification of Diseases version 10 (ICD-10) discharge coding was completed for each admission by the principal investigator and compared with the corresponding admission data captured for each patient within the Clinicom® Health Information System. Agreement comparison was done to both four-character and three-character ICD-10 code specificity. Results: Of the initial 450 randomly selected folders, 396 (88%) were analysed during the folder review process. The median number of total diagnoses (primary diagnosis plus secondary diagnoses) coded by the principal investigator (PI) folder review was 3 with a distribution of 1 to 10 (IQR 2 - 4). The median number of total diagnoses coded in Clinicom® was 1 with a distribution of 1 to 3 (IQR 1 - 1). Agreement of primary diagnosis coding to four characters was 26.3% with slight improvement to 34.3% when assessed to three characters. Agreement for secondary diagnoses to four characters was 14.9% and 27.7% when assessed to three characters. Conclusion: Reliability of administrative discharge data from RCWMCH is poor. Inadequacies with regard to the employment of dedicated and/or adequately trained coding personnel may be significant contributors to the problem.
dc.identifier.apacitationDaniels, A. (2018). <i>Examining the reliability of discharge ICD coding in the Red Cross War Memorial Children's Hospital administrative database</i>. (). University of Cape Town ,Faculty of Health Sciences ,Department of Paediatrics and Child Health. Retrieved from http://hdl.handle.net/11427/29811en_ZA
dc.identifier.chicagocitationDaniels, Adriaan. <i>"Examining the reliability of discharge ICD coding in the Red Cross War Memorial Children's Hospital administrative database."</i> ., University of Cape Town ,Faculty of Health Sciences ,Department of Paediatrics and Child Health, 2018. http://hdl.handle.net/11427/29811en_ZA
dc.identifier.citationDaniels, A. 2018. Examining the reliability of discharge ICD coding in the Red Cross War Memorial Children's Hospital administrative database. University of Cape Town.en_ZA
dc.identifier.ris TY - Thesis / Dissertation AU - Daniels, Adriaan AB - Background: Discharge diagnostic data from hospital administrative databases are often used to inform decisions relating to a variety of vital applications. These may include the allocation of resources, quality of care assessments, clinical research and for the formulation of healthcare policy to name a few. Having accurately coded and reliably captured discharge data for patients is of paramount importance for any hospital and health system to function efficiently. Objectives: 1. Retrospectively examine the reliability of the ICD discharge coding in the Red Cross War Memorial Children’s Hospital (RCWMCH) administrative database for primary and secondary discharge diagnoses. 2. Formulate recommendations for improvement to the current system. Methods: This study was a retrospective folder review of 450 patient admissions to the short stay and general paediatric wards at the RCWMCH between 1 August 2013 and 1 September 2014. International Classification of Diseases version 10 (ICD-10) discharge coding was completed for each admission by the principal investigator and compared with the corresponding admission data captured for each patient within the Clinicom® Health Information System. Agreement comparison was done to both four-character and three-character ICD-10 code specificity. Results: Of the initial 450 randomly selected folders, 396 (88%) were analysed during the folder review process. The median number of total diagnoses (primary diagnosis plus secondary diagnoses) coded by the principal investigator (PI) folder review was 3 with a distribution of 1 to 10 (IQR 2 - 4). The median number of total diagnoses coded in Clinicom® was 1 with a distribution of 1 to 3 (IQR 1 - 1). Agreement of primary diagnosis coding to four characters was 26.3% with slight improvement to 34.3% when assessed to three characters. Agreement for secondary diagnoses to four characters was 14.9% and 27.7% when assessed to three characters. Conclusion: Reliability of administrative discharge data from RCWMCH is poor. Inadequacies with regard to the employment of dedicated and/or adequately trained coding personnel may be significant contributors to the problem. DA - 2018 DB - OpenUCT DP - University of Cape Town LK - https://open.uct.ac.za PB - University of Cape Town PY - 2018 T1 - Examining the reliability of discharge ICD coding in the Red Cross War Memorial Children's Hospital administrative database TI - Examining the reliability of discharge ICD coding in the Red Cross War Memorial Children's Hospital administrative database UR - http://hdl.handle.net/11427/29811 ER - en_ZA
dc.identifier.urihttp://hdl.handle.net/11427/29811
dc.identifier.vancouvercitationDaniels A. Examining the reliability of discharge ICD coding in the Red Cross War Memorial Children's Hospital administrative database. []. University of Cape Town ,Faculty of Health Sciences ,Department of Paediatrics and Child Health, 2018 [cited yyyy month dd]. Available from: http://hdl.handle.net/11427/29811en_ZA
dc.language.isoeng
dc.publisher.departmentDepartment of Paediatrics and Child Health
dc.publisher.facultyFaculty of Health Sciences
dc.publisher.institutionUniversity of Cape Town
dc.subject.otherPaediatrics
dc.titleExamining the reliability of discharge ICD coding in the Red Cross War Memorial Children's Hospital administrative database
dc.typeMaster Thesis
dc.type.qualificationlevelMasters
dc.type.qualificationnameMMed
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