基于单中心病案首页的甲状腺癌诊断与手术操作编码质量评估

Assessment of the quality of diagnosis and surgical procedure coding for thyroid cancer on the front page of medical records in a single center

摘要:

背景与目的 住院病案首页作为医疗信息化建设中的核心数据源，其准确性直接影响科研数据的可用性与医疗决策的科学性。甲状腺恶性肿瘤具有诊断和治疗流程相对标准化的特点，是评估病案首页数据质量的重要代表性病种。本研究旨在系统评价病案首页中甲状腺恶性肿瘤诊断及手术操作编码的准确性，分析其存在的问题，并探讨改进策略与未来在临床研究中的应用前景。方法 回顾性纳入2018年1月—2020年12月在昆明医科大学第一附属医院甲状腺外科接受初次手术治疗并确诊为甲状腺癌的3 361例患者，分别以术后病理报告和手术记录作为诊断与手术范围的标准，评估病案首页主要诊断编码、次要诊断编码、主要手术操作编码及次要手术操作编码的准确性。结果 主诊断编码准确率达98.8%；但在1 368例伴颈部淋巴结转移的病例中，仅31.2%的次要诊断编码和转移部位录入规范，漏报率高达67.8%。主要手术操作编码正确率为90.4%，其中单侧甲状腺切除术（TL）和甲状腺全切术（TT）的编码准确率分别为85.5%和96.0%；编码错误中，TL误报为TT占70.0%。其他手术操作（主要为淋巴结清扫）编码种类繁多，存在多达14种不同编码类型，反映出编码标准缺失及录入不统一的问题。2020年主要手术编码错误率较前两年明显升高，提示人工录入存在主观误差及质量波动。结论 本研究揭示甲状腺恶性肿瘤病案首页数据中存在以手术操作编码为主的准确性缺陷，可能影响真实世界数据的科研价值。未来应通过人工智能技术辅助诊疗信息结构化与编码自动化，并构建多学科协作的主动质控体系，以提高病案首页数据质量，夯实甲状腺癌精准诊疗、绩效考核、医保支付及科研应用的数据基础。

Abstract:

Background and Aims As a core data source in the development of medical informatization, the front page of inpatient medical records plays a crucial role in determining the usability of research data and the scientific quality of clinical decision-making. Given the relatively standardized diagnostic and treatment protocols for thyroid malignancies, this disease serves as a representative model for evaluating the data quality of medical record front sheets. This study aimed to systematically assess the accuracy of diagnostic and surgical procedure coding for thyroid malignancies on the medical record front page, identify existing problems, and explore strategies for improvement and the potential for future application in clinical research.Methods A total of 3 361 patients who underwent initial surgical treatment and were pathologically confirmed with thyroid cancer at the Department of Thyroid Surgery, the First Affiliated Hospital of Kunming Medical University from January 2018 to December 2020 were retrospectively included. Postoperative pathology reports and surgical records were used as reference standards to evaluate the accuracy of primary and secondary diagnosis codes, as well as primary and secondary surgical procedure codes on the medical record front page.Results The accuracy rate of primary diagnosis coding reached 98.8%. However, among 1 368 patients with cervical lymph node metastasis, only 31.2% had correctly recorded secondary diagnosis codes and metastatic sites, with an omission rate as high as 67.8%. The overall accuracy rate for primary surgical procedure coding was 90.4%, with thyroid lobectomy (TL) and total thyroidectomy (TT) coding accuracies of 85.5% and 96.0%, respectively. Among the coding errors, 70.0% involved TL procedures being incorrectly coded as TT. Secondary surgical procedure codes—mainly for lymph node dissection—were highly inconsistent, with up to 14 different coding types, reflecting a lack of standardization and unified input criteria. Notably, the error rate for primary surgical coding in 2020 increased significantly compared with the previous two years, suggesting subjectivity and variability in manual data entry.Conclusion This study highlights major accuracy deficiencies in surgical procedure coding for thyroid malignancies on the medical record front page, which may compromise the scientific validity of real-world data. Going forward, leveraging artificial intelligence technologies to support structured documentation and automated coding, alongside establishing a proactive quality control system through multidisciplinary collaboration, may significantly improve data accuracy. These efforts are essential for strengthening data foundations for precision treatment, performance evaluation, insurance payment, and clinical research on thyroid cancer.