Concordance of diagnosis between statistical information and clinical history of patients with cardiopulmonary diseases

Raraz-Vidal J.; Raraz-Vidal O.; Velásquez V.; Gonzales G.F. · Revista Cubana de Investigaciones Biomedicas (2024)

Resumen

Introduction: Respiratory and cardiac diseases result frequent causes of hospital care and present a high mortality rate in Latin America. Aim: To determine the concordance between the diagnosis recorded by the statistics office and the diagnosis in the emergency clinical history in patients with cardiopulmonary diseases in three public hospitals in Lima during 2010-2015. Methods: A descriptive, retrospective, cross-sectional, retrospective study was conducted in the archive area of three public hospitals. The medical records of patients with cardiopulmonary diseases, admitted to the Internal Medicine and Pediatrics Service, were reviewed. The diagnoses of the statistical record and the emergency record of the clinical history were compared. Concordance was measured with Cohen's Kappa coefficient, and sensitivity and specificity were also estimated. Results: Of 540 medical records reviewed, only 31.2 % had the emergency admission record and 33.8 % had the discharge criteria. Fourteen percent were incomplete and without diagnosis. The vast majority were patients with respiratory diseases (72%). The most frequent conditions in pediatric patients were acute bronchial obstruction syndrome, pneumonia and asthma. Cardiac conditions corresponded to adult patients: stroke and acute myocardial infarction. There was a correspondence (91%) between the diagnosis recorded by the computer office and the diagnosis on the emergency care card. Sensitivity resulted in 95.7 % and specificity in 96.7 %. Conclusions: The study determined a good diagnostic concordance between the statistical information and the clinical history. Data were considered reliable due to their high sensitivity and specificity.

Instituciones: Universidad Peruana Cayetano Heredia; Universidad Nacional Hermilio Valdizán