Multisite medical record review of emergency department visits for traumatic brain injury

Comparison of different definitions of traumatic brain injury: implications for cohort characteristics and survival in women, Philadelphia, USA

BACKGROUND

Traumatic brain injury (TBI) is an acute injury that is understudied in civilian cohorts, especially among women, as TBI has historically been considered to be largely a condition of athletes and military service people. Both the Centres for Disease Control and Prevention (CDC) and Department of Defense (DOD)/Veterans Affairs (VA) have developed case definitions to identify patients with TBI from medical records; however, their definitions differ. We sought to re-examine these definitions to construct an expansive and more inclusive definition among a cohort of women with TBI.

METHODS

In this study, we use electronic health records (EHR) from a single healthcare system to study the impact of using different case definitions to identify patients with TBI. Specifically, we identified adult female patients with TBI using the CDC definition, DOD/VA definition and a combined and expanded definition herein called the Penn definition.

RESULTS

We identified 4446 adult-female TBI patients meeting the CDC definition, 3619 meeting the DOD/VA definition, and together, 6432 meeting our expanded Penn definition that includes the CDC ad DOD/VA definitions.

CONCLUSIONS

Using the expanded definition identified almost two times as many patients, enabling investigations to more fully characterise these patients and related outcomes. Our expanded TBI case definition is available to other researchers interested in employing EHRs to investigate TBI.

Effect of continuous hypertonic saline infusion on clinical outcomes in patients with traumatic brain injury

Osmotic therapy has been recognized as an important treatment option for patients with traumatic brain injury (TBI). Nevertheless, the effect of hypertonic saline (HTS) remains unknown, as findings are primarily based on a large database. This study aimed to elucidate the effect of HTS on the clinical outcomes of patients with TBI admitted to the intensive care unit (ICU). We retrospectively identified patients with moderate-to-severe TBI from two public databases: Medical Information Mart for Intensive Care (MIMIC)-IV and eICU Collaborative Research Database (eICU-CRD). A marginal structural Cox model (MSCM) was used, with time-dependent variates designed to reflect exposure over time during ICU stay. Trajectory modeling based on the intracranial pressure evolution pattern allowed for the identification of subgroups. Overall, 130 (6.65%) of 1955 eligible patients underwent HTS. MSCM indicated that the HTS significantly associated with higher infection complications (e.g., urinary tract infection (HR 1.88, 95% CI 1.26-2.81, p = 0.002)) and increased ICU LOS (HR 2.02, 95% CI 1.71-2.40, p < 0.001). A protective effect of HTS on GCS was found in subgroups with medium and low intracranial pressure. Our study revealed no significant difference in mortality between patients who underwent HTS and those who did not. Increased occurrence rates of infection and electrolyte imbalance are inevitable outcomes of continuous HTS infusion. Although the study suggests slight beneficial effects, including better neurological outcomes, these results warrant further validation.

Trends in ICD-10-CM-Coded Administrative Datasets for Injury Surveillance and Research

Injury surveillance relies heavily on data created for administrative purposes. In the United States, the adoption of the clinical modification of the 10th edition of the International Classification of Diseases, Tenth Revision, Clinical Modification added thousands of potential injury codes, but few are used in administrative datasets. The widespread use of electronic health records has the potential to influence the data sources used for injury surveillance. This investigation explores how trends in clinical coding may affect the consistency of injury surveillance data.

Objectives

Accurate injury surveillance depends on data quality in administrative datasets created for billing and reimbursement. Significant effort has been devoted to testing the ability of candidate injury case definitions to identify injury cases accurately in these datasets. We used interviews with experienced coders, informed by a review of the current literature, to identify three clinical coding trends that may affect the consistency of surveillance data: “clinical documentation improvement or clinical documentation integrity” (CDI), coding by treating clinicians, and certain electronic health record features.

Methods

An extensive literature review informed interviews with coding experts to identify potential issues in coding practice. To determine whether physician coding was associated with information loss, we analyzed data from two hospitals serving the same geographic area. One hospital had used physician coding of emergency department data for the past decade; the other used professional coders. We compared the proportion of emergency department records missing external cause of injury codes and assessed the variation for statistical significance.

Results

CDI audits review patient records to ensure that billing information includes every relevant International Classification of Diseases, Tenth Revision, Clinical Modification code. This approach has increased payment rates awarded to Medicare Advantage plans because additional codes increase the patient acuity level and case mix index. The impact of CDI audits on injury data needs further investigation. The pilot analysis addressing information loss with physician coding found a higher level of external cause coding with clinician self-coding, possibly because of the coding software. Finally, widespread “copy and paste” in patient electronic health records has the potential to increase reported injuries.

Conclusions

Injury surveillance relies on billing and reimbursement records. Financial motivations may interfere with the consistency of surveillance findings and mislead injury epidemiologists. Further investigation is essential to ensure the integrity of surveillance findings.

Multi-site medical record review for validation of intentional self-harm coding in emergency departments

BACKGROUND

Codes in the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM), are used for injury surveillance, including surveillance of intentional self-harm, as they appear in administrative billing records. This study estimated the positive predictive value of ICD-10-CM codes for intentional self-harm in emergency department (ED) billing records for patients aged 10 years and older who did not die and were not admitted to an inpatient medical service.

METHODS

The study team in Maryland, Colorado, and Massachusetts selected all or a random sample of ED billing records with an ICD-10-CM code for intentional self-harm (specific codes that began with X71-X83, T36-T65, T71, T14.91). Positive predictive value (PPV) was determined by the number and percentage of records with a physician diagnosis of intentional self-harm, based on a retrospective review of the original medical record.

RESULTS

The estimated PPV for the codes' capture of intentional self-harm based on physician diagnosis in the original medical record was 89.8% (95% CI 85.0-93.4) for Maryland records, 91.9% (95% CI 87.7-95.0) for Colorado records, and 97.3% (95% CI 95.1-98.7) for Massachusetts records.

CONCLUSION

Given the high PPV of the codes, epidemiologists can use the codes for public health surveillance of intentional self-harm treated in the ED using ICD-10-CM coded administrative billing records. However, these codes and related variables in the billing database cannot definitively distinguish between suicidal and non-suicidal intentional self-harm.

Practitioners Assess Achievements and Challenges of Nonfatal Injury Surveillance

OBJECTIVE

Injury surveillance relies on data coded for administrative rather than epidemiological accuracy. The Centers for Disease Control and Prevention (CDC) established the 5-year Surveillance Quality Improvement (SQI) initiative to advance consensus and methodology for injury epidemiology reporting and analysis. Evaluation of the positive predictive value of the CDC's injury surveillance definitions based on International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) and International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) coding in designated injury categories comprised much of the SQI initiative's work. The goal of the current study is to identify achievements and challenges in SQI as articulated by experienced injury epidemiology practitioners who participated in the CDC-funded SQI initiative.

DESIGN, SETTING, AND PARTICIPANTS

We conducted semistructured interviews with 12 representatives of state and federal public health agencies who had participated extensively in the SQI initiative. The interviews were transcribed and coded using NVivo qualitative analysis software. Initial coding of the data involved both in vivo coding (using the words of participants) and coding of a priori themes.

MAIN OUTCOME MEASURES

Qualitative analysis identified 2 overarching themes, variability among states and observations on the science of injury surveillance.

RESULTS

Within the 2 broad themes, the respondents provided valuable insights regarding access to medical records, case definition validation, unique contributions of medical record abstracting, variations in the practice of medical coding, and the potential for use of data from medical record reviews in other injury-related areas.

CONCLUSIONS

The contributions of the SQI initiative have provided valuable insights into ICD-10-CM case definitions for national injury surveillance. Challenges remain with regard to data access and quality with ongoing reliance on administrative datasets for injury surveillance.

Interrupted time series design to evaluate ICD-9-CM to ICD-10-CM coding changes on trends in Colorado emergency department visits related to traumatic brain injury

Background

The transition in 2015 to the Tenth Revision of the International Classification of Disease, Clinical Modification (ICD-10-CM) in the US led the Centers for Disease Control and Prevention (CDC) to propose a surveillance definition of traumatic brain injury (TBI) utilizing ICD-10-CM codes. The CDC’s proposed surveillance definition excludes “unspecified injury of the head,” previously included in the ICD-9-CM TBI surveillance definition. The study purpose was to evaluate the impact of the TBI surveillance definition change on monthly rates of TBI-related emergency department (ED) visits in Colorado from 2012 to 2017.

Results

The monthly rate of TBI-related ED visits was 55.6 visits per 100,000 persons in January 2012. This rate in the transition month to ICD-10-CM (October 2015) decreased by 41 visits per 100,000 persons (p-value < 0.0001), compared to September 2015, and remained low through December 2017, due to the exclusion of “unspecified injury of head” (ICD-10-CM code S09.90) in the proposed TBI definition. The average increase in the rate was 0.33 visits per month (p < 0.01) prior to October 2015, and 0.04 visits after. When S09.90 was included in the model, the monthly TBI rate in Colorado remained smooth from ICD-9-CM to ICD-10-CM and the transition was no longer significant (p = 0.97).

Conclusion

The reduction in the monthly TBI-related ED visit rate resulted from the CDC TBI surveillance definition excluding unspecified head injury, not necessarily the coding transition itself. Public health practitioners should be aware that the definition change could lead to a drastic reduction in the magnitude and trend of TBI-related ED visits, which could affect decisions regarding the allocation of TBI resources. This study highlights a challenge in creating a standardized set of TBI ICD-10-CM codes for public health surveillance that provides comparable yet clinically relevant estimates that span the ICD transition.