Does the International Classification of Disease (ICD-9) code accurately identify neonates who clinically have hypoxic-ischemic encephalopathy?

Risk factors for neonatal encephalopathy in late preterm and term singleton births in a large California birth cohort

OBJECTIVE

The objective was to investigate maternal and pregnancy characteristics associated with neonatal encephalopathy (NE).

STUDY DESIGN

We queried an administrative birth cohort from California between 2011 and 2017 to determine the association between each factor and NE with and without hypothermia treatment.

RESULTS

From 3 million infants born at 35 or more weeks of gestation, 6,857 cases of NE were identified (2.3 per 1000 births), 888 (13%) received therapeutic hypothermia. Risk factors for NE were stronger among cases receiving hypothermia therapy. Substance-related diagnosis, preexisting diabetes, preeclampsia, and any maternal infection were associated with a two-fold increase in risk. Maternal overweight/obesity, nulliparity, advanced maternal age, depression, gestational diabetes or hypertension, and short or long gestations also predicted NE. Young maternal age, Asian race and Hispanic ethnicity, and cannabis-related diagnosis lowered risk of NE.

CONCLUSIONS

By disseminating these results, we encourage further interrogation of these perinatal factors.

Association between newborn screening analytes and hypoxic ischemic encephalopathy

Hypoxic ischemic encephalopathy (HIE) is a major cause of neonatal mortality and morbidity. Our study sought to examine whether patterns of newborn screening analytes differed between infants with and without neonatal HIE in order to identify opportunities for potential use of these analytes for diagnosis in routine clinical practice. We linked a population-based newborn screening registry with health databases to identify cases of HIE among term infants (≥37 weeks' gestation) in Ontario from 2010-2015. Correlations between HIE and screening analytes were examined using multivariable logistic regression models containing clinical factors and individual screening analytes (acyl-carnitines, amino acids, fetal-to-adult hemoglobin ratio, endocrine markers, and enzymes). Among 731,841 term infants, 3,010 were diagnosed with HIE during the neonatal period. Multivariable models indicated that clinical variables alone or in combination with hemoglobin values were not associated with HIE diagnosis. Although the model was improved after adding acyl-carnitines and amino acids, the ability of the model to identify infants with HIE was moderate. Our findings indicate that analytes associated with catabolic stress were altered in infants with HIE; however, future research is required to determine whether amino acid and acyl-carnitine profiles could hold clinical utility in the early diagnosis or clinical management of HIE. In particular, further research should examine whether cord blood analyses can be used to identify HIE within a clinically useful timeframe or to guide treatment and predict long-term health outcomes.

Asphyxia in the Newborn: Evaluating the Accuracy of ICD Coding, Clinical Diagnosis and Reimbursement: Observational Study at a Swiss Tertiary Care Center on Routinely Collected Health Data from 2012-2015

BACKGROUND

The ICD-10 categories of the diagnosis "perinatal asphyxia" are defined by clinical signs and a 1-minute Apgar score value. However, the modern conception is more complex and considers metabolic values related to the clinical state. A lack of consistency between the former clinical and the latter encoded diagnosis poses questions over the validity of the data. Our aim was to establish a refined classification which is able to distinctly separate cases according to clinical criteria and financial resource consumption. The hypothesis of the study is that outdated ICD-10 definitions result in differences between the encoded diagnosis asphyxia and the medical diagnosis referring to the clinical context.

METHODS

Routinely collected health data (encoding and financial data) of the University Hospital of Bern were used. The study population was chosen by selected ICD codes, the encoded and the clinical diagnosis were analyzed and each case was reevaluated. The new method categorizes the diagnoses of perinatal asphyxia into the following groups: mild, moderate and severe asphyxia, metabolic acidosis and normal clinical findings. The differences of total costs per case were determined by using one-way analysis of variance.

RESULTS

The study population included 622 cases (P20 "intrauterine hypoxia" 399, P21 "birth asphyxia" 233). By applying the new method, the diagnosis asphyxia could be ruled out with a high probability in 47% of cases and the variance of case related costs (one-way ANOVA: F (5, 616) = 55.84, p < 0.001, multiple R-squared = 0.312, p < 0.001) could be best explained. The classification of the severity of asphyxia could clearly be linked to the complexity of cases.

CONCLUSION

The refined coding method provides clearly defined diagnoses groups and has the strongest effect on the distribution of costs. It improves the diagnosis accuracy of perinatal asphyxia concerning clinical practice, research and reimbursement.

Defining a Patient Population With Cirrhosis: An Automated Algorithm With Natural Language Processing

OBJECTIVES

The objective of this study was to use natural language processing (NLP) as a supplement to International Classification of Diseases, Ninth Revision (ICD-9) and laboratory values in an automated algorithm to better define and risk-stratify patients with cirrhosis.

BACKGROUND

Identification of patients with cirrhosis by manual data collection is time-intensive and laborious, whereas using ICD-9 codes can be inaccurate. NLP, a novel computerized approach to analyzing electronic free text, has been used to automatically identify patient cohorts with gastrointestinal pathologies such as inflammatory bowel disease. This methodology has not yet been used in cirrhosis.

STUDY DESIGN

This retrospective cohort study was conducted at the University of California, Los Angeles Health, an academic medical center. A total of 5343 University of California, Los Angeles primary care patients with ICD-9 codes for chronic liver disease were identified during March 2013 to January 2015. An algorithm incorporating NLP of radiology reports, ICD-9 codes, and laboratory data determined whether these patients had cirrhosis. Of the 5343 patients, 168 patient charts were manually reviewed at random as a gold standard comparison. Positive predictive value (PPV), negative predictive value (NPV), sensitivity, and specificity of the algorithm and each of its steps were calculated.

RESULTS

The algorithm's PPV, NPV, sensitivity, and specificity were 91.78%, 96.84%, 95.71%, and 93.88%, respectively. The NLP portion was the most important component of the algorithm with PPV, NPV, sensitivity, and specificity of 98.44%, 93.27%, 90.00%, and 98.98%, respectively.

CONCLUSIONS

NLP is a powerful tool that can be combined with administrative and laboratory data to identify patients with cirrhosis within a population.

Shoulder dystocia: definitions and incidence

Though subjective in nature, both the American College of Obstetricians and Gynecologists practice bulletin and the Royal College of Obstetricians and Gynaecologists green guideline are in agreement on the descriptor of shoulder dystocia: requirement of additional obstetric maneuvers when gentle downward traction has failed to affect the delivery of the shoulders. The rate of shoulder dystocia is about 1.4% of all deliveries and 0.7% for vaginal births. Compared to non-diabetics (0.6%), among diabetics, the rate of impacted shoulders is 201% higher (1.9%); newborns delivered by vacuum or forceps have 254% higher likelihood of shoulder dystocia than those born spontaneously (2.0% vs. 0.6%, respectively). When the birthweight is categorized as <4000, 4000-4449, and >4500 g, the likelihood of shoulder dystocia in the US vs. other countries varies significantly. Future studies should focus on lowering the rate of shoulder dystocia and its associated morbidities, without concomitantly increasing the rate of cesarean delivery.

Prematurity, asphyxia and congenital malformations underrepresented among neonates in a tertiary pediatric hospital in Vietnam

BACKGROUND

Estimated 17,000 neonates (≤ 28 days of age) die in Vietnam annually, corresponding to more than half of the child mortality burden. However, current knowledge about these neonates is limited. Prematurity, asphyxia and congenital malformations are major causes of death in neonates worldwide. To improve survival and long term development, these vulnerable neonates need access to the specialized neonatal care existing, although limited, in lower middle-income countries like Vietnam. The aim of this study was to describe these conditions in a specialized Vietnamese hospital, compared to a Danish hospital.

METHODS

We performed a comparative observational study of all neonates admitted to a tertiary pediatric hospital in South Vietnam in 2009-2010. The data were prospectively extracted from the central hospital registry and included basic patient characteristics and diagnoses (International Classification of Diseases, 10th revision). Prematurity, asphyxia and designated congenital malformations (oesophageal atresia, gastroschisis, omphalocoele, diaphragmatic hernia and heart disease) were investigated. In a subgroup, the prematurity diagnosis was validated using a questionnaire. The hospitalization ratio of each diagnosis was compared to those obtained from a Danish tertiary hospital. The Danish data were retrieved from the neonatal department database for a ten-year period.

RESULTS

The study included 5763 neonates (missing<1%). The catchment population was 726,578 live births. The diagnosis was prematurity in 7%, asphyxia in 2% and one of the designated congenital malformations in 6%. The diagnosis of prematurity was correctly assigned to 85% of the neonates, who were very premature or had very low birth weight according to the questionnaire, completed by 2196 neonates. Compared to the Danish Hospital, the hospitalization ratios of neonates diagnosed with prematurity (p<0.01), asphyxia (p<0.01) and designated congenital malformations (p<0.01- 0.04) were significantly lower.

CONCLUSION

Our findings suggest the investigated diagnoses were underrepresented in the Vietnamese study hospital. In contrast, relatively mild diagnoses were frequent. These results indicate the use of specialized care may not be optimal. Pre-hospital selection mechanisms were not investigated and additional studies are needed to optimise utilisation of specialized care and improve neonatal survival.