A new standardized nomenclature in neurosurgery: Criteria and quantitative and qualitative evaluation indicators of medical procedures

Ángel Horcajadas Almansa , Luis Ley Urzaiz , Roberto Garcia Leal , Francisco González Llanos , Mónica Lara Almunia , Ruben Martinez Laez , Jose M. Torres Campa , Idoia Zaspe Cenoz , Jesús Lafuente Baraza
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Abstract

Purpose

Update the list of medical acts in the specialty of Neurosurgery, eliminating obsolete acts and adding the new surgical techniques developed in recent years, so that they are faithfully adapted to the usual medical practice of our specialty, as well as establishing the general principles and defining the grading criteria, quantitative indicators and assessment scales.

Methods

The elaboration of the new nomenclator was divided into 3 phases: 1) identification and selection of medical acts, 2) establishment of the degree of difficulty of each of them based on the experience and the time necessary for their completion, as well as the percentage and severity of the possible complications and 3) consensus with the members of the SENEC through their individualized submission, making the necessary adjustments and subsequent approval in the general assembly of SENEC.

Results

The new nomenclator has 255 medical acts grouped into 4 groups: consultations and visits, therapeutic acts, diagnostic procedures and surgical interventions. 42 procedures included in the OMC nomenclator have been eliminated due to being obsolete, not related to the specialty or being too vague. New techniques have been included and medical acts have been more precisely defined.

Conclusions

This nomenclator provides up-to-date terminology and will serve to offer the portfolio of services, measure and know the relative value of our activity and the approximate costs of the procedures, and additionally, to carry out longitudinal comparative studies. It should be a tool to improve patient care and minimise geographic variability in all healthcare settings.

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新的神经外科标准化术语:医疗程序的标准及定量和定性评价指标。
目的:更新神经外科专业的医疗行为清单,剔除过时的行为,增加近年来发展的新的外科技术,使其忠实地适应本专业的常规医疗实践,同时确立一般原则,确定分级标准、量化指标和评估尺度:新术语表的制定分为 3 个阶段:1) 确定和选择医疗行为;2) 根据经验和完成医疗行为所需的时间,以及可能出现的并发症的比例和严重程度,确定每项医疗行为的难度;3) 通过提交个性化意见,与 SENEC 成员达成共识,进行必要的调整,随后在 SENEC 大会上批准:新术语表将 255 项医疗行为分为 4 组:会诊和出诊、治疗行为、诊断程序和手术干预。由于过时、与专业无关或过于模糊,OMC 术语表中的 42 种程序已被删除。新技术被纳入其中,医疗行为的定义也更加精确:该术语表提供了最新术语,将有助于提供服务组合,衡量和了解我们活动的相对价值和程序的大致成本,此外,还有助于开展纵向比较研究。它应该成为改善病人护理的工具,并最大限度地减少所有医疗环境中的地域差异。
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