Assessing the Accuracy of International Classification of Diseases (ICD) Coding for Delirium

Association between Intraoperative Hypotension and Postoperative Delirium: A Retrospective Cohort Analysis

BACKGROUND

Intraoperative hypotension might contribute to the development of postoperative delirium through inadequate cerebral perfusion. However, evidence regarding the association between intraoperative hypotension and postoperative delirium is equivocal. Therefore, the hypothesis that intraoperative hypotension is associated with postoperative delirium in patients older than 70 yr having elective noncardiac surgery was tested .

METHODS

This was a retrospective cohort analysis of patients older than 70 yr who underwent elective noncardiac surgery in a single tertiary academic center between 2020 and 2021. Intraoperative hypotension was quantified as the area under a mean arterial pressure (MAP) threshold of 65 mmHg. Postoperative delirium was defined as a collapsed composite outcome including a positive 4 A's test during the initial 2 postoperative days, and/or delirium identification using the Chart-based Delirium Identification Instrument. The association between hypotension and postoperative delirium was assessed using multivariable logistic regression, adjusting for potential confounding variables. Several sensitivity analyses were performed using similar regression models.

RESULTS

In total, 2,352 patients were included (median age, 76 yr; 1,112 [47%] women; 1,166 [50%] American Society of Anesthesiologists Physical Status III or greater; 698 [31%] having high-risk surgeries). The median [interquartile range] intraoperative area under the curve below a threshold of MAP less than 65 mmHg was 28 [0, 103] mmHg · min. The overall incidence of postoperative delirium was 14% (327 of 2,352). After adjustment for potential confounding variables, hypotension was not associated with postoperative delirium. Compared to the first quartile of area under the curve below a threshold of MAP less than 65 mmHg, patients in the second, third, and fourth quartiles did not have more postoperative delirium, with adjusted odds ratios of 0.94 (95% CI, 0.64 to 1.36; P = 0.73), 0.95 (95% CI, 0.66 to 1.36; P = 0.78), and 0.95 (95% CI, 0.65 to 1.36; P = 0.78), respectively. Intraoperative hypotension was also not associated with postoperative delirium in any of the sensitivity and subgroup analyses performed.

CONCLUSIONS

To the extent of hypotension observed in our cohort, our results suggest that intraoperative hypotension is not associated with postoperative delirium in elderly patients having elective noncardiac surgery.

EDITOR’S PERSPECTIVE

Incidence and relative risk of delirium after major surgery for patients with pre-operative depression: a systematic review and meta-analysis

BACKGROUND

Delirium is a common and potentially serious complication after major surgery. A previous history of depression is a known risk factor for experiencing delirium in patients admitted to the hospital, but the generalised risk has not been estimated in surgical patients.

METHODS

We conducted a systematic review and meta-analysis of studies reporting the incidence or relative risk (or relative odds) of delirium in the immediate postoperative period for adults with pre-operative depression. We included studies that defined depression as either a formal pre-existing diagnosis or having clinically important depressive symptoms measured using a patient-reported instrument before surgery. Multilevel random effects meta-analyses were used to estimate the pooled incidences and pooled relative risks. We also conducted subgroup analyses by various study-level characteristics to identify important moderators of pooled estimates.

RESULTS

Forty-two studies (n = 4,664,051) from five continents were included. The pooled incidence of postoperative delirium for patients with pre-operative depression was 29% (95%CI 17-43%, I2 = 99.0%), compared with 15% (95%CI 6-28%, I2 = 99.8%) in patients without pre-operative depression and 21% (95% CI 11-33%, I2 = 99.8%) in the cohorts overall. For patients with pre-operative depression, the risk of delirium was 1.91 times greater (95%CI 1.68-2.17, I2 = 42.0%) compared with patients without pre-operative depression.

CONCLUSIONS

Patients with a previous diagnosis of depression or clinically important depressive symptoms before surgery have substantially greater risk of experiencing delirium after surgery. Clinicians and patients should be informed of these increased risks. Robust screening and other risk mitigation strategies for postoperative delirium are warranted, especially for patients with pre-operative depression.

Associations Between COVID-19, Delirium, and 1-Year Mortality: Exploring Influences on Delirium Incidence in COVID-19 Patients

BACKGROUND

This study investigated the relationship between coronavirus disease 2019 (COVID-19), delirium, and 1-year mortality. Factors associated with delirium in COVID-19 patients were identified, along with the influence of psychotropic medications on delirium.

METHODS

The study used the South Korean National Health Insurance Service database. Adult COVID-19 patients diagnosed between October 2020 and December 2021 were included, with a propensity score-matched control group. Time-dependent Cox regression assessed associations among COVID-19, delirium, and mortality. Logistic regression analyzed the impact of psychotropic medications on delirium incidence.

RESULTS

The study included 832,602 individuals, with 416,301 COVID-19 patients. COVID-19 (hazard ratio [HR], 3.03; 95% confidence interval [CI], 2.92-3.13) and delirium (HR, 2.33; 95% CI, 2.06-2.63) were independent risk factors for 1-year mortality. Comorbidities, insurance type, and residence were also related to mortality. Among COVID-19 patients, antipsychotic use was associated with lower delirium incidence (odds ratio [OR], 0.38; 95% CI, 0.30-0.47), while mood stabilizers (OR, 1.77; 95% CI, 1.40-2.21) and benzodiazepines (OR, 8.62; 95% CI, 7.46-9.97) were linked to higher delirium incidence.

CONCLUSION

COVID-19 and delirium are risk factors for 1-year mortality. Some factors associated with delirium in COVID-19 patients are modifiable and can be targeted in preventive and therapeutic interventions.

The Role of Delirium on Short- and Long-Term Postoperative Outcomes Following Major Gastrointestinal Surgery for Cancer

INTRODUCTION

The growing burden of an aging population has raised concerns about demands on healthcare systems and resources, particularly in the context of surgical and cancer care. Delirium can affect treatment outcomes and patient recovery. We sought to determine the prevalence of postoperative delirium among patients undergoing digestive tract surgery for malignant indications and to analyze the role of delirium on surgical outcomes.

METHODS

Medicare claims data were queried to identify patients diagnosed with esophageal, gastric, hepatobiliary, pancreatic, and colorectal cancers between 2018 and 2021. Postoperative delirium, occurring within 30 days of operation, was identified via International Classification of Diseases, 10th edition codes. Clinical outcomes of interested included "ideal" textbook outcome (TO), characterized as the absence of complications, an extended hospital stay, readmission within 90 days, or mortality within 90 days. Discharge disposition, intensive care unit (ICU) utilization, and expenditures also were examined.

RESULTS

Among 115,654 cancer patients (esophageal: n = 1854, 1.6%; gastric: n = 4690, 4.1%; hepatobiliary: n = 6873, 5.9%; pancreatic: n = 8912, 7.7%; colorectal: n = 93,325, 90.7%), 2831 (2.4%) were diagnosed with delirium within 30 days after surgery. On multivariable analysis, patients with delirium were less likely to achieve TO (OR 0.27 [95% CI 0.25-0.30]). In particular, patients who experienced delirium had higher odds of complications (OR 3.00 [2.76-3.25]), prolonged length of stay (OR 3.46 [3.18-3.76]), 90-day readmission (OR 1.96 [1.81-2.12]), and 90-day mortality (OR 2.78 [2.51-3.08]). Furthermore, patients with delirium had higher ICU utilization (OR 2.85 [2.62-3.11]). Upon discharge, patients with delirium had a decreased likelihood of being sent home (OR 0.40 [0.36-0.46]) and instead were more likely to be transferred to a skilled nursing facility (OR 2.17 [1.94-2.44]). Due to increased utilization of hospital resources, patients with delirium incurred in-hospital expenditures that were 55.4% higher (no delirium: $16,284 vs. delirium: $28,742) and 90-day expenditures that were 100.7% higher (no delirium: $2564 vs. delirium: $8226) (both p < 0.001). Notably, 3-year postoperative survival was adversely affected by delirium (no delirium: 55.5% vs. delirium: 37.3%), even after adjusting risk for confounding factors (HR 1.79 [1.70-1.90]; p < 0.001).

CONCLUSIONS

Postoperative delirium occurred in one in 50 patients undergoing surgical resection of a digestive tract cancer. Delirium was linked to a reduced likelihood of achieving an optimal postoperative outcome, increased ICU utilization, higher expenditures, and a worse long-term prognosis. Initiatives to prevent delirium are vital to improve postoperative outcomes among cancer surgery patients.

Psychiatric diagnoses are common after liver transplantation and are associated with increased health care utilization and patient financial burden

Psychiatric disorders after liver transplantation (LT) are associated with worse patient and graft outcomes, which may be amplified by inadequate treatment. We aimed to characterize the burden of psychiatric disorders, treatment patterns, and associated financial burden among liver transplantation recipients (LTRs). IQVIA PharMetrics (R) Plus for Academics-a large health plan claims database representative of the commercially insured US population-was used to identify psychiatric diagnoses among adult LTRs and assess treatment. Multivariable logistic regression analysis identified factors associated with post-LT psychiatric diagnoses and receipt of pharmacotherapy. Patient financial liability was estimated using adjudicated medical/pharmacy claims for LTRs with and without psychiatric diagnoses. Post-LT psychiatric diagnoses were identified in 395 (29.5%) of 1338 LTRs, of which 106 (26.8%) were incident cases. Treatment varied, with 67.3% receiving pharmacotherapy, 32.1% psychotherapy, 21.0% combination therapy, and 21.5% no treatment. Among 340 LTRs on psychotropic medications before transplant, 24% did not continue them post-LT. Post-LT psychiatric diagnoses were independently associated with female sex, alcohol-associated liver disease (ALD), prolonged LT hospitalization (>2 wk), and pre-LT psychiatric diagnosis. Incident psychiatric diagnoses were associated with female sex, ALD, and prolonged LT hospitalization. Patients with a post-LT psychiatric diagnosis had higher rates of hospitalization (89.6% vs. 81.5%, p <0.001) and financial liability (median $5.5K vs. $4.6K USD, p =0.006). Having a psychiatric diagnosis post-LT was independently associated with experiencing high financial liability >$5K. Over 1 in 4 LTRs had a psychiatric diagnosis in a large national cohort, yet nearly a quarter received no treatment. LTRs with psychiatric diagnoses experienced increased health care utilization and higher financial liability. Sociodemographic and clinical risk factors could inform high-risk subgroups who may benefit from screening and mitigation strategies.

The impact of the COVID-19 pandemic on longitudinal trends of surgical mortality and inpatient quality of care in Ontario, Canada

AIMS

Previous studies have shown the COVID-19 pandemic was associated with reductions in volume across a spectrum of non-SARS-CoV-2 hospitalizations. In the present study, we examine the impact of the pandemic on patient safety and quality of care.

DESIGN

This is a retrospective population-based study of discharge abstracts.

METHODS

We applied a set of nationally validated indicators for measuring the quality of inpatient care to hospitalizations in Ontario, Canada between January 2010 and December 2022. We measured 90-day mortality after selected types of higher risk admissions (such as cancer surgery and cardiovascular emergency) and the rate of patient harm events (such as delirium, pressure injuries and hospital-acquired infections) occurring during the hospital stay.

RESULTS

A total 13,876,377 hospitalization episodes were captured. Compared with the pre-pandemic period, and independent of SARS-CoV-2 infection, the pandemic period was associated with higher rates of mortality after bladder cancer resection (adjusted risk ratio [aRR] 1.20 (1.07-1.34)) and open repair for abdominal aortic aneurysm (aRR 1.45 (1.06-1.99)). The pandemic was also associated with higher rates of delirium (adjusted odds ratio [aOR] 1.04 (1.02-1.06)), venous thromboembolism (aOR 1.10 (1.06-1.13)), pressure injuries (aOR 1.28 (1.24-1.33)), aspiration pneumonitis (aOR 1.15 (1.12-1.18)), urinary tract infections (aOR 1.02 (1.01-1.04)), Clostridiodes difficile infection (aOR 1.05 (1.02-1.09)), pneumothorax (aOR 1.08 (1.03-1.13)), and use of restraints (aOR 1.12 (1.10-1.14)), but was associated with lower rates of viral gastroenteritis (aOR 0.22 (0.18-0.28)). During the pandemic, SARS-CoV-2-positive admissions were associated with a higher likelihood of various harm events.

CONCLUSION

The COVID-19 pandemic was associated with higher rates of patient harm for a wide range of non-SARS-CoV-2 inpatient populations.

IMPACT

Understanding which quality measures are improving or deteriorating can help health systems prioritize quality improvement initiatives.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

Former smoking, but not active smoking, is associated with delirium in postoperative ICU patients: a matched case-control study

Objective

To examine the relationship between current and former smoking and the occurrence of delirium in surgical Intensive Care Unit (ICU) patients.

Methods

We conducted a single center, case-control study involving 244 delirious and 251 non-delirious patients that were admitted to our ICU between 2018 and 2022. Using propensity score analysis, we obtained 115 pairs of delirious and non-delirious patients matched for age and Simplified Acute Physiology Score II (SAPS II). Both groups of patients were further stratified into non-smokers, active smokers and former smokers, and logistic regression was performed to further investigate potential confounders.

Results

Our study revealed a significant association between former smoking and the incidence of delirium in ICU patients, both in unmatched (adjusted odds ratio (OR): 1.82, 95% confidence interval (CI): 1.17-2.83) and matched cohorts (OR: 3.0, CI: 1.53-5.89). Active smoking did not demonstrate a significant difference in delirium incidence compared to non-smokers (unmatched OR = 0.98, CI: 0.62-1.53, matched OR = 1.05, CI: 0.55-2.0). Logistic regression analysis of the matched group confirmed former smoking as an independent risk factor for delirium, irrespective of other variables like surgical history (p = 0.010). Notably, also respiratory and vascular surgeries were associated with increased odds of delirium (respiratory: OR: 4.13, CI: 1.73-9.83; vascular: OR: 2.18, CI: 1.03-4.59). Medication analysis showed that while Ketamine and Midazolam usage did not significantly correlate with delirium, Morphine use was linked to a decreased likelihood (OR: 0.27, 95% CI: 0.13-0.55).

Discussion

Nicotine's complex neuropharmacological impact on the brain is still not fully understood, especially its short-term and long-term implications for critically ill patients. Although our retrospective study cannot establish causality, our findings suggest that smoking may induce structural changes in the brain, potentially heightening the risk of postoperative delirium. Intriguingly, this effect seems to be obscured in active smokers, potentially due to the recognized neuroprotective properties of nicotine. Our results motivate future prospective studies, the results of which hold the potential to substantially impact risk assessment procedures for surgeries.

Identification and information management of cognitive impairment of patients in acute care hospitals: An integrative review

Objectives

Recognition of the cognitive status of patients is important so that care can be tailored accordingly. The objective of this integrative review was to report on the current practices that acute care hospitals use to identify people with cognitive impairment and how information about cognition is managed within the healthcare record as well as the approaches required and recommended by policies.

Methods

Following Whittemore & Knafl's five-step method, we systematically searched Medline, CINAHL, and Scopus databases and various grey literature sources. Articles relevant to the programs that have been implemented in acute care hospitals regarding the identification of cognitive impairment and management of cognition information were included. The Mixed Methods Appraisal Tool and AACODS (Authority, Accuracy, Coverage, Objectivity, Date, Significance) Checklist were used to evaluate the quality of the studies. Thematic analysis was used to present and synthesise results. This review was pre-registered on PROSPERO ( CRD42022343577).

Results

Twenty-two primary studies and ten government/industry publications were included in the analysis. Findings included gaps between practice and policy. Although identification of cognitive impairment, transparency of cognition information, and interaction with patients, families, and carers (if appropriate) about this condition were highly valued at a policy level, sometimes in practice, cognitive assessments were informal, patient cognition information was not recorded, and interactions with patients, families, and carers were lacking.

Discussion

By incorporating cognitive assessment, developing an integrated information management system using information technology, establishing relevant laws and regulations, providing education and training, and adopting a national approach, significant improvements can be made in the care provided to individuals with cognitive impairment.

Delirium in older adults after percutaneous coronary intervention: Prevalence, risks, and clinical phenotypes

INTRODUCTION

In-hospital delirium is more common among older adults and is associated with increased mortality and adverse health-related outcomes. We aim to establish the contemporary prevalence of delirium among older adults undergoing percutaneous coronary intervention (PCI) and the impact of delirium on in-hospital complications.

METHODS

We identified older adults aged ≥75 years in the National Inpatient Sample who underwent inpatient PCI for any reason from 2016 to 2020 and stratified them into those with and without delirium. The primary outcome was in-hospital mortality, and secondary outcomes encompassed post-procedural complications.

RESULTS

Delirium occurred in 14,130 (2.6 %) hospitalizations in which PCI was performed. Patients who developed delirium were older and had more comorbidities. Patients with in-hospital delirium had higher odds of in-hospital mortality (adjusted odds ratio [aOR] 1.27, p = 0.002) and non-home discharge (aOR 3.17, p < 0.001). Delirium was also associated with higher odds of intracranial hemorrhage (aOR 2.49, p < 0.001), gastrointestinal hemorrhage (aOR 1.25, p = 0.030), need for blood transfusion (aOR 1.52, p < 0.001), acute kidney injury (aOR 1.62, p < 0.001), and fall in hospital (aOR 1.97, p < 0.001).

CONCLUSION

Delirium among older adults undergoing PCI is relatively common and associated with higher odds of in-hospital mortality and adverse events. This highlights the importance of vigilant delirium prevention and early recognition in the peri-procedural setting, especially for older adults.

Clinical Prediction Models for Hospital-Induced Delirium Using Structured and Unstructured Electronic Health Record Data: Protocol for a Development and Validation Study

BACKGROUND

Hospital-induced delirium is one of the most common and costly iatrogenic conditions, and its incidence is predicted to increase as the population of the United States ages. An academic and clinical interdisciplinary systems approach is needed to reduce the frequency and impact of hospital-induced delirium.

OBJECTIVE

The long-term goal of our research is to enhance the safety of hospitalized older adults by reducing iatrogenic conditions through an effective learning health system. In this study, we will develop models for predicting hospital-induced delirium. In order to accomplish this objective, we will create a computable phenotype for our outcome (hospital-induced delirium), design an expert-based traditional logistic regression model, leverage machine learning techniques to generate a model using structured data, and use machine learning and natural language processing to produce an integrated model with components from both structured data and text data.

METHODS

This study will explore text-based data, such as nursing notes, to improve the predictive capability of prognostic models for hospital-induced delirium. By using supervised and unsupervised text mining in addition to structured data, we will examine multiple types of information in electronic health record data to predict medical-surgical patient risk of developing delirium. Development and validation will be compliant to the Transparent Reporting of a multivariable prediction model for Individual Prognosis Or Diagnosis (TRIPOD) statement.

RESULTS

Work on this project will take place through March 2024. For this study, we will use data from approximately 332,230 encounters that occurred between January 2012 to May 2021. Findings from this project will be disseminated at scientific conferences and in peer-reviewed journals.

CONCLUSIONS

Success in this study will yield a durable, high-performing research-data infrastructure that will process, extract, and analyze clinical text data in near real time. This model has the potential to be integrated into the electronic health record and provide point-of-care decision support to prevent harm and improve quality of care.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/48521.

Trends in delirium coding rates in older hospital inpatients in England and Scotland: full population data comprising 7.7M patients per year show substantial increases between 2012 and 2020

Background

Little information is available on change in delirium coding rates over time in major healthcare systems. We examined trends in delirium discharge coding rates in older patients in hospital admissions to the National Health Service (NHS) in England and Scotland between 2012 and 2020.

Methods

Hospital administrative coding data were sourced from NHS Digital England and Public Health Scotland. We examined rates of delirium (F05 from ICD-10) in patients aged ≥70 years in 5 year and ≥90 age bands.

Results

There were approximately 7,000,000 discharges/year in England and 700,000/year in Scotland. Substantially increased delirium coding was observed for all age bands between 2012/2013 and 2019/2020 (p<0.001, Mann Kendall's tau). In the ≥90 age band, there was a 4-fold increase between 2012 and 2020.

Conclusion

Delirium coding rates have shown large increases in the NHS in England and Scotland, likely reflecting several factors including policy initiatives, detection tool implementation and education.