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系統識別號 U0026-0812200913361069
論文名稱(中文) 以醫院資訊系統監測術後感染的可行性評估 :以關節置換術為例
論文名稱(英文) Feasibility of Using Hospital Information System to Detect Post-operative Infection : Arthroplasty as an example
校院名稱 成功大學
系所名稱(中) 公共衛生研究所
系所名稱(英) Graduate Institute of Public Health
學年度 95
學期 1
出版年 96
研究生(中文) 趙翎妤
研究生(英文) Ling-Yu Chao
學號 T8693106
學位類別 碩士
語文別 中文
論文頁數 104頁
口試委員 口試委員-賴國安
指導教授-呂宗學
口試委員-陳國東
口試委員-柯文謙
中文關鍵字 醫院資訊系統  人工關節置換術後感染  準確度  健保申報資料  感染控制監測 
英文關鍵字 health information system  post-operative prosthetic joint infection  claims data  infection control surveillance  accuracy 
學科別分類
中文摘要 研究背景:越來越多的醫療保健研究使用保險申報資料進行分析,也有不少研究使用保險申報資料進行手術部位感染的監測分析。最快速簡單使用保險申報資料監測疾病就是使用ICD-9-CM出院診斷編碼進行個案界定,但是也有研究顯示ICD-9-CM出院診斷編碼的準確度可能不佳。

研究目的:首先想探討以ICD-9-CM出院診斷編碼偵測初次人工關節置換術後感染的可行性,是過度註碼或低度註碼?其次想暸解手術部位、性別、年齡、手術年代、手術原因、伴隨疾病是否為影響人工關節置換術後感染監測準確度的危險因子。

研究材料及方法:本研究首先翻閱民國91年所有於此醫學中心進行初次人工關節置換術的病歷,篩選疑似人工關節置換術後感染個案,經專家小組確認為真正感染的個案,再與健保申報ICD-9-CM出院診斷編碼比較並找出相關因素。透過這些相關因素選擇民國88年至92年有初次人工關節置換術後感染高危險個案進行病歷翻閱,同樣請專家小組確認真正感染個案,再與健保申報ICD-9-CM出院診斷編碼比較,計算一致度、敏感度、特異度與陽性預測值,同時分析影響高低估的相關因素。

研究結果:翻閱民國91年病歷同時經過專家小組確認的人工關節置換術後感染,有部分被錯誤編碼為ICD-9-CM編碼996.4(骨科內在植入物的醫療併發症)。因此民國88-92年之手術個案只選擇出院診斷有ICD-9-CM編碼996.4者進行病歷翻閱與專家小組確認。五年個案中出院診斷編碼996.66(人工關節置換術後感染)的28人中,只有22位經專家確認後為真正感染者(高估七人),這些個案大多是傷口感染而非關節感染。相反地,23位出院診斷編碼996.64當中,有2位經專家確認後為真正感染者。影響高估的因素包括:膝關節置換術、女性、手術年齡小於65歲等。

結論:以健保申報ICD-9-CM出院診斷編碼監測人工關節置換術後感染是可行的,但是使用出院診斷編碼996.66還是有高估情形,因此必須進一步翻閱病歷確認。本研究結果也可提供疾病分類人員教育訓練參考,釐清手術後關節感染與傷口感染之差異。
英文摘要 Background: More and more health services researches used claims data for analysis and have been used in a surveillance of surgical site infection (SSI). The quickest way to define the SSI cases was to use the ICD-9-CM discharge diagnosis. Nevertheless, studies also revealed the quality of ICD-9-CM coding.

Objective: The first aim of this study was to assess the feasibility of using ICD-9-CM discharge diagnosis to identify postoperative prosthetic joint infection (POPJI), whether it was over-coded or under-coded. The second aim was to determine the factors associated with the over-coded.

Methods: We reviewed the medical records of all patients who received primary joint replacement operation in 1992 to screen the possible POPJI cases and were confirmed by panels of experts. We also identified the characteristics of possible POPJI to screen all patients from 1999 through 2003. After identify the real POPJI cases, we then calculated the agreement rate, sensitivity, specificity and positive predict value and analyze the associated factors of over-coding.

Results: After we reviewed medical records of all patients who received primary joint replacement operation in 1992 and confirmed by panels, we found that some of the POPJI would be erroneously coded as ICD-9-CM code 996.64 (Mechanical complication of internal orthopedic device, implant, and graft). We thus used ICD-9-CM code 996.64 to screen the patients from 1988 through 2003. Of 28 cases with discharge main diagnosis coded as ICD-9-CM code 996.66, only 22 of them were confirmed by panels as POPJI. The six over-coded cases were those with post-operative wound infection. On the other hand, of 23 patients with ICD-9-CM code 996.64, only 2 of them were confirmed by panel as POPJI. Factors associated with over-code included: primary knee replacement, female, and those aged under 65 years old.

Conclusions: It is feasible to use hospital information system to detect POPJI. There was over-code of using ICD-9-CM code 996.66, thus the medical record review was needed to confirm the cases. Our findings could provide teaching materials for coder to avoid over-code post-operative wound infection as joint infection.
論文目次 考試合格證明 i
中文摘要 ii
英文摘要 iv
致謝 vi
內容目錄 viii
表目錄 x
圖目錄 xi
第一章 前言 1
第二章 文獻探討 3
 1.監測系統 3
 2.保險申報疾病診斷準確度 6
 3.手術後感染的監測 9
 4.人工關節置換術後感染診斷的困難度 11
第三章 研究目的 13
第四章 研究方法 14
 1.資料來源 14
 2.人工關節置換術後感染的判定 18
 3.資料分析 21
第五章 研究結果 29
第六章 討論 51
第七章 參考文獻 62

表目錄
表1、保險申報疾病診斷準確度 71
表2、民國88年至民國92年進行初次人工關節置換術病患的描述型分析   74
表3、健保申報出院診斷感染與專家確認感染的分層感染率 75
表4、髖關節置換術後,健保申報出院診斷感染與專家確認感染的分層   感染率 76
表5、膝關節置換術後,健保申報出院診斷感染與專家確認感染的分層   感染率 77
表6、健保申報出院診斷感染與專家確認感染之比較—不同特徵別 78
表7、健保申報出院診斷高估感染的可能危險因子分析 79
表8、健保申報出院診斷正確估計感染的個案基本分析 80
表9、健保申報出院診斷高低估感染之個案基本分析 82
表10、健保申報出院診斷低估感染之個案分析 83
表11、健保申報出院診斷高估感染之個案分析 89

圖目錄
圖1、單年資料(民國91年)分析主要流程與結果 101
圖2、多年資料(民國88年至民國92年)分析主要流程與結果
   健保申報出院診斷ICD-9-CM為996.66的病患 102
圖3、多年資料(民國88年至民國92年)分析主要流程與結果
   健保申報出院診斷ICD-9-CM為996.4的病患 103
圖4、多年資料(民國88年至民國92年)分析主要流程與結果
   健保申報出院診斷ICD-9-CM為996.66與996.4的病患 104
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