The importance of considering both primary and secondary diagnostic codes when using administrative health data to study acute coronary syndrome epidemiology (ANZACS-QI 47)

Association of Psychiatric Emergency Visits and Warm Ambient Temperature during Pregnancy: A Time-Stratified Case-Crossover Study

BACKGROUND

Acute exposure to high ambient temperature and heat waves during the warm season has been linked with psychiatric disorders. Emerging research has shown that pregnant people, due to physiological and psychological changes, may be more sensitive to extreme heat, and acute exposure has been linked to increased risk of pregnancy complications; however, few studies have examined psychiatric complications.

OBJECTIVE

Our objective was to examine the association between acute exposure to warm ambient temperatures and emergency department (ED) visits for mental disorders during pregnancy.

METHODS

A time-stratified case-crossover design with conditional logistic regression was performed on ∼ 206,000 psychiatric ED visits for pregnant patients in North Carolina, from May to September 2016 to 2019. Daily average ambient temperature was the main exposure and was linked to daily visits by maternal zip code of residence for prenatal mood and anxiety disorders (PMAD), severe mental illness (SMI), mental disorder of pregnancy (MDP), suicidal thoughts (SUIC), and any psychiatric disorder (Any). Effect modification by trimester, residential segregation, economic segregation, urbanicity, and availability of greenspace was also investigated.

RESULTS

Each 5 ° C increase in same-day exposure to warm ambient temperature on case days was associated with an increase in incidence rate ratio (IRR) for any psychiatric disorder [IRR = 1.07; 95% confidence interval (CI): 1.01, 1.14] including anxiety (IRR = 1.14; 95% CI: 1.00, 1.30), bipolar disorder (IRR = 1.28; 95% CI: 0.98, 1.67), and suicidal thoughts (IRR = 1.28; 95% CI: 1.00, 1.65) compared to control days. In general, the associations were strongest for warm season temperatures on the same day of exposure or for temperatures averaged over the 3 or 6 d preceding the ED visit. The greatest risk of an incident ED admission for PMAD (RR = 1.20; 95% CI: 1.04, 1.39), particularly for anxiety (RR = 1.30; 95% CI: 1.07, 1.59), and any psychiatric disorder (RR = 1.17; 95% CI: 1.07, 1.28) occurred following cumulative exposure to hot temperatures the week before admission. Higher psychiatric burden from temperature was observed in urban areas and on extreme heat days.

CONCLUSIONS

For this pregnant population in the southeastern United States, short-term exposure to high ambient temperatures during the warm season was associated with a greater risk of ED visits for an array of psychiatric disorders. Findings show that climate-related increases in ambient temperature may contribute to psychiatric morbidity in pregnant people. https://doi.org/10.1289/EHP13293.

Numerical Cincinnati Stroke Scale versus Stroke Severity Screening Tools for the Prehospital Determination of LVO

Background

Previous research demonstrated that the numerical Cincinnati Prehospital Stroke Scale (CPSS) identifies large vessel occlusion (LVO) at similar rates compared to a limited number of stroke severity screening tools. We aimed to compare numerical CPSS to additional stroke scales using a national EMS database.

Methods

Using the ESO Data Collaborative, the largest EMS database with hospital linked data, we retrospectively analyzed prehospital patient records for the year 2022. Stroke and LVO diagnoses were determined by ICD-10 codes from linked hospital discharge and emergency department records. Prehospital CPSS was compared to the Cincinnati Stroke Triage Assessment Tool (C-STAT), the Field Assessment Stroke Triage for Emergency Destination (FAST-ED), and the Balance Eyes Face Arm Speech Time (BE-FAST). The optimal prediction cut-points for LVO screening were determined by intersecting the sensitivity and specificity curves for each scale. To compare the discriminative abilities of each scale among those diagnosed with LVO, we used the area under the receiver operating curve (AUROC).

Results

We identified 17,442 prehospital records from 754 EMS agencies with ≥ 1 documented stroke scale of interest: 30.3% (n=5,278) had a hospital diagnosis of stroke, of which 71.6% (n=3,781) were ischemic; of those, 21.6% (n=817) were diagnosed with LVO. CPSS score ≥ 2 was found to be predictive of LVO with 76.9% sensitivity, 68.0% specificity, and AUROC 0.787 (95% CI 0.722-0.801). All other tools had similar predictive abilities, with sensitivity / specificity / AUROC of: C-STAT 62.5% / 76.5% / 0.727 (0.555-0.899); FAST-ED 61.4% / 76.1%/ 0.780 (0.725-0.836); BE-FAST 70.4% / 67.1% / 0.739 (0.697-0.788).

Conclusion

The less complex CPSS exhibited comparable performance to three frequently employed LVO detection tools. EMS agency leadership, medical directors, stroke system directors, and other stroke leaders may consider the complexity of stroke severity instruments and challenges with ensuring accurate recall and consistent application when selecting which instrument to implement. Use of the simpler CPSS may enhance compliance with the utilization of LVO screening instruments while maintaining the accuracy of prehospital LVO determination.

The short-term effects and burden of particle air pollution on hospitalization for coronary heart disease: a time-stratified case-crossover study in Sichuan, China

BACKGROUND

Coronary heart disease (CHD), the leading cause of death globally, might be developed or exacerbated by air pollution, resulting high burden to patients. To date, limited studies have estimated the relations between short-term exposure to air pollution and CHD disease burden in China, with inconsistent results. Hence, we aimed to estimate the short-term impact and burden of ambient PM pollutants on hospitalizations of CHD and specific CHD.

METHODS

PM10 and PM2.5 were measured at 82 monitoring stations in 9 cities in Sichuan Province, China during 2017-2018. Based on the time-stratified case-crossover design, the effects of short-term exposure to particle matter (PM) pollution on coronary heart disease (CHD) hospital admissions were estimated. Meanwhile, the linked burden of CHD owing to ambient PM pollution were estimated.

RESULTS

A total of 104,779 CHD records were derived from 153 hospitals from these 9 cities. There were significant effects of PM pollution on hospital admissions (HAs) for CHD and specific CHD in Sichuan Province. A 10 μg/m3 increase of PM10 and PM2.5 was linked with a 0.46% (95% CI: 0.08, 0.84%), and 0.57% (95% CI: 0.05, 1.09%) increments in HAs for CHD at lag7, respectively. The health effects of air pollutants were comparable modified by age, season and gender, showing old (≥ 65 years) and in cold season being more vulnerable to the effects of ambient air pollution, while gender-specific effects is positive but not conclusive. Involving the WHO's air quality guidelines as the reference, 1784 and 2847 total cases of HAs for CHD could be attributable to PM10 and PM2.5, separately. The total medical cost that could be attributable to exceeding PM10 and PM2.5 were 42.04 and 67.25 million CNY from 2017 to 2018, respectively.

CONCLUSIONS

This study suggested that the short-term exposure to air pollutants were associated with increased HAs for CHD in Sichuan Province, which could be implications for local environment improvement and policy reference.

Major adverse cardiovascular event definitions used in observational analysis of administrative databases: a systematic review

Background

Major adverse cardiovascular events (MACE) are increasingly used as composite outcomes in randomized controlled trials (RCTs) and observational studies. However, it is unclear how observational studies most commonly define MACE in the literature when using administrative data.

Methods

We identified peer-reviewed articles published in MEDLINE and EMBASE between January 1, 2010 to October 9, 2020. Studies utilizing administrative data to assess the MACE composite outcome using International Classification of Diseases 9th or 10th Revision diagnosis codes were included. Reviews, abstracts, and studies not providing outcome code definitions were excluded. Data extracted included data source, timeframe, MACE components, code definitions, code positions, and outcome validation.

Results

A total of 920 articles were screened, 412 were retained for full-text review, and 58 were included. Only 8.6% (n = 5/58) matched the traditional three-point MACE RCT definition of acute myocardial infarction (AMI), stroke, or cardiovascular death. None matched four-point (+unstable angina) or five-point MACE (+unstable angina and heart failure). The most common MACE components were: AMI and stroke, 15.5% (n = 9/58); AMI, stroke, and all-cause death, 13.8% (n = 8/58); and AMI, stroke and cardiovascular death 8.6% (n = 5/58). Further, 67% (n = 39/58) did not validate outcomes or cite validation studies. Additionally, 70.7% (n = 41/58) did not report code positions of endpoints, 20.7% (n = 12/58) used the primary position, and 8.6% (n = 5/58) used any position.

Conclusions

Components of MACE endpoints and diagnostic codes used varied widely across observational studies. Variability in the MACE definitions used and information reported across observational studies prohibit the comparison, replication, and aggregation of findings. Studies should transparently report the administrative codes used and code positions, as well as utilize validated outcome definitions when possible.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12874-021-01440-5.

Distribution, management and outcomes of AMI according to principal diagnosis priority during inpatient admission

BACKGROUND

In recent years, there has been a growing interest in outcomes of patients with acute myocardial infarction (AMI) using large administrative datasets. The present study was designed to compare the characteristics, management strategies and acute outcomes between patients with primary and secondary AMI diagnoses in a national cohort of patients.

METHODS

All hospitalisations of adults (≥18 years) with a discharge diagnosis of AMI in the US National Inpatient Sample from January 2004 to September 2015 were included, stratified by primary or secondary AMI. The International Classification of Diseases, ninth revision and Clinical Classification Software codes were used to identify patient comorbidities, procedures and clinical outcomes.

RESULTS

A total of 10 864 598 weighted AMI hospitalisations were analysed, of which 7 186 261 (66.1%) were primary AMIs and 3 678 337 (33.9%) were secondary AMI. Patients with primary AMI diagnoses were younger (median 68 vs 74 years, P < .001) and less likely to be female (39.6% vs 48.5%, P < .001). Secondary AMI was associated with lower odds of receipt of coronary angiography (aOR 0.19; 95%CI 0.18-0.19) and percutaneous coronary intervention (0.24; 0.23-0.24). Secondary AMI was associated with increased odds of MACCE (1.73; 1.73-1.74), mortality (1.71; 1.70-1.72), major bleeding (1.64; 1.62-1.65), cardiac complications (1.69; 1.65-1.73) and stroke (1.68; 1.67-1.70) (P < .001 for all).

CONCLUSIONS

Secondary AMI diagnoses account for one-third of AMI admissions. Patients with secondary AMI are older, less likely to receive invasive care and have worse outcomes than patients with a primary diagnosis code of AMI. Future studies should consider both primary and secondary AMI diagnoses codes in order to accurately inform clinical decision-making and health planning.