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Arizona Birth Defects Monitoring Program
Case Finding Process
|Case Finding Procedure:||Case finding is a strategy used to identify potential cases of infants who may have a reportable birth defect, diagnosed within the first year of life. This requires that the Arizona Birth Defects Monitoring Program (ABDMP) staff merge the lists of potential cases from various data sources to eliminate duplicates and assure complete case ascertainment. A final list is prepared for the corresponding medical facility with a request to retrieve charts for review.|
|Abstracting:||Reporting rules (Arizona Administrative Code Title 9, Chapter 4) define the access of the ABDMP to information on infants who may birth defects from various data sources. The ABDMP staff to review the charts and abstract the cases, which meet the criteria for inclusion (see Case Definition).|
|Coding:||The ABDMP staff code the birth defects using British Pediatric Association (BPA) codes.|
|Data Entry:||The abstracts are entered into the oracle data base after being checked or completeness and accuracy.|
|Routine Quality Control:||The first
level of quality control involves the review by the ABDMP Program Manager
of all (100%) of the abstracts prepared by the abstractors for completeness and
accuracy prior to data entry. A complete item-by-item inspection is undertaken
to determine if the required data is recorded and the data is accurate and
consistent. In addition, each recorded diagnosis with its confirmation and its
selected BPA code is reviewed for accuracy by referring to the information
entered in the Results of Diagnostic Tests and Procedures Narrative section of
the abstract and by referring to the coding instructions for reportable
congenital anomalies. Resolution of any errors, omissions, or
inconsistencies is accomplished during the discussions with the responsible
When a case is identified from several facilities, the abstracts of that case are merged. The Program Manager analyzes the findings to look for the final diagnoses and make corrections to the abstracts.
|Case Finding Audit:||Annually 20% of the hospitals/facilities are randomly selected for case finding audits. A case finding list is prepared from a sample of the hospital's Disease Index and other case finding sources for comparison with the original case finding list created. If more than 5% of the probable cases do not appear on the original case finding list, a 100% audit will be conducted, and the ABDMP staff will receive additional training to improve the case finding process used.|
|Re-Abstraction Study:||Annually 10
to 50% of the abstracts from 20% of the hospitals/facilities are randomly
selected for the re-abstracting study (the percentage of abstracts selected for
audit depends on the size of the hospital/facility). The quality assurance
person (QAP) reviews each chart and re-abstracts reportable data to evaluate the
|Data Entry Verification:||The QAP
verifies the data entry of a sample of abstracts (20%) of the year of interest
by accessing the ABDMP automated system to compare what was entered to what was
recorded on each abstract. If the frequency of accuracy is less than 95%,
then a 100% audit will be performed on the data entry.
To achieve and maintain quality of data and to be cost-effective, the ABDMP provides to the staff complete documentation of abstracting and coding rules, formal and informal training and timely feedback.