ArticleBJGP open2020
GP coding behaviour for non-specific clinical presentations: a pilot study.
Article in BJGP open, 2020. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 9 papers.
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Who cites it
9 citing papers in PubMed.
- Impact of the MHRA safety update on vitamin BBMC primary care · 2025Article
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- Validation of Algorithms to Detect Acute and Disseminated Lyme Disease in U.S. Administrative Claims Data.Open forum infectious diseases · 2025Article
- Article
- Primary healthcare professionals' approach to clinical coding: a qualitative interview study in Wales.The British journal of general practice : the journal of the Royal College of General Practitioners · 2025Article
- Severe mental illness as a risk factor for recorded diagnosis of osteoporosis and fragility fractures in people aged ≥50 years: retrospective cohort study using UK primary care data.The British journal of general practice : the journal of the Royal College of General Practitioners · 2024Article
- Validation of the recording of idiopathic pulmonary fibrosis in routinely collected electronic healthcare records in England.BMC pulmonary medicine · 2023Article
- Has COVID-19 affected dementia diagnosis rates in England?International journal of geriatric psychiatry · 2023Article
- Clinical Management of COPD in the Real World: Can Studies Reveal Errors in Management and Pathways to Improve Patient Care?Pragmatic and observational research · 2023Review
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Authors and funding
6 authors.
Funding
No grant is acknowledged in the PubMed record.
Abstract
backgroundClinical coding is an integral part of primary care. Disease incidence studies based on primary care electronic health records (EHRs) rely on the accuracy of these codes. Current code validation methods are not appropriate for non-specific conditions and provide limited information about GPs' decision-making behaviour around coding. Qualitative methods could offer insight into decision-making behaviour around coding of patients with non-specific conditions.
aimTo investigate the decision-making behaviour of GPs when applying Read codes to non-specific clinical presentations, using Lyme disease as a case example. DESIGN &
settingA pilot study was undertaken, involving masked semi-structured interviews of eight GPs in the North West of England.
methodSemi-structured interviews were carried out based on 11 clinical cases representative of Lyme disease presentations. Discrete answers were described descriptively. Interview transcripts were analysed using a thematic approach.
resultsThemes underpinning GPs' coding behaviour included: GP personal and professional experience; clinical evidence; diagnostic uncertainty; professional integrity and defensive practice; and patient-sourced health information and beliefs. GPs placed Lyme disease on their differential diagnosis list for five cases; in only two cases would GPs select a Lyme disease related Read code.
conclusionGPs were reluctant to code with specific diagnostic Read codes when they were presented with patients with vague or unfamiliar symptomology. This masked questionnaire methodology offers a new approach to validate incidence figures, based on Read codes of non-specific conditions. The reluctance to code poses many problems for primary care EHRs research. Further research is needed to understand what drives GPs' coding behaviour.
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