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Presumptive coding. A preliminary study of the aggregation of input diagnoses to determine their relevance to clinical governance and urological resourcing
Author(s) -
Payne S.R.,
NapierHemy R.D.,
Ganesan T.,
Turner W.H.
Publication year - 2004
Publication title -
bju international
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 1.773
H-Index - 148
eISSN - 1464-410X
pISSN - 1464-4096
DOI - 10.1111/j.1464-410x.2003.04671.x
Subject(s) - relevance (law) , medical diagnosis , corporate governance , coding (social sciences) , business , medicine , political science , sociology , pathology , law , social science , finance
OBJECTIVE To determine the validity of a system for coding the reason for urological referral from primary care, using ICD10, and thus enable benchmarking of urological outpatient activity. PATIENTS AND METHODS Four studies were conducted: (i) A pilot study to aggregate information into a few input diagnosis codes (925 patients); (ii) Validation of the aggregated codes using input diagnoses from a second centre (928 patients); (iii) A prospective study by three urologists to determine the system's generic utility (918 patients); (iv) A study to aggregate the presumptive codes for 2771 patients to gain an insight into the case‐mix of patients referred to a general urological service via the outpatient department. RESULTS The aggregation of input diagnoses from general practice referrals into 36 ‘presumptive codes’ was possible and could be validated. Prospective coding, for 96% of eligible patients, was possible with < 1% of referral diagnoses not being codable. Further aggregation of the data for 2771 patients showed that 31% were referred with urological malignancy whilst 69% had symptoms suggesting benign urological disease. CONCLUSIONS This preliminary study of presumptive coding suggests that it is a feasible and valid method of recording the input diagnoses for patients presented to a urological service. The information it provides has relevance for the structuring, benchmarking, resourcing and manpower requirements of that service, essential components for clinical governance. It also has relevance to the prospective collection of patient data for research and audit.