Injury coding in a national trauma registry: a one-year validation audit in a level 1 trauma centre

Missing patient registrations in the Dutch National Trauma Registry of Southwest Netherlands: Prevalence and epidemiology

INTRODUCTION

Health care patient records have been digitalised the past twenty years, and registries have been automated. Missing registrations are common, and can result in selection bias.

OBJECTIVE

To assess the prevalence and characteristics of missed registrations in a Dutch regional trauma registry.

METHODS

An automatically generated trauma registry export was done for ten out of eleven hospitals in trauma region Southwest Netherlands, between June 1 and August 31, 2020. Second, lists were checked for being falsely flagged as 'non-trauma'. Finally, a list was generated with trauma tick box flagged as 'trauma' but were not automatically in the export due to administrative errors. Automated and missed registration datasets were compared on patient characteristics and logistic regression models were run with random intercepts and missed registration as outcome variable on the complete dataset.

RESULTS

A total of 2,230 automated registrations and 175 (7.3 %) missed registrations were included for the Dutch National Trauma Registry, ranging from 1 to 14 % between participating hospitals. Patients of the missed registration dataset had characteristics of a higher level of care, compared with patients of automated registrations. Level of trauma care (level II OR 0.464 95 % CI 0.328-0.666, p < 0.001; level III OR 0.179 95 % CI 0.092-0.325, p < 0.001), major trauma (OR 2.928 95 % CI 1.792-4.65, p < 0.001), ICU admission (OR 2.337 95 % CI 1.792-4.650, p < 0.001), and surgery (OR 1.871 95 % CI 1.371-2.570, p < 0.001) were potential predictors for missed registrations in multivariate logistic regression analysis.

CONCLUSION

Missed registrations occur frequently and the rate of missed registrations differs greatly between hospitals. Automated and missed registration datasets display differences related to patients requiring more intensive care, which held for the major trauma subset. Checking for missed registrations is time consuming, automated registration lists need a human touch for validation and to be complete.

Excellent agreement of Norwegian trauma registry data compared to corresponding data in electronic patient records

BACKGROUND

The Norwegian Trauma Registry (NTR) is designed to monitor and improve the quality and outcome of trauma care delivered by Norwegian trauma hospitals. Patient care is evaluated through specific quality indicators, which are constructed of variables reported to the registry by certified registrars. Having high-quality data recorded in the registry is essential for the validity, trust and use of data. This study aims to perform a data quality check of a subset of core data elements in the registry by assessing agreement between data in the NTR and corresponding data in electronic patient records (EPRs).

METHODS

We validated 49 of the 118 variables registered in the NTR by comparing those with the corresponding ones in electronic patient records for 180 patients with a trauma diagnosis admitted in 2019 at eight public hospitals. Agreement was quantified by calculating observed agreement, Cohen's Kappa and Gwet's first agreement coefficient (AC1) with 95% confidence intervals (CIs) for 27 nominal variables, quadratic weighted Cohen's Kappa and Gwet's second agreement coefficient (AC2) for five ordinal variables. For nine continuous, one date and seven time variables, we calculated intraclass correlation coefficient (ICC).

RESULTS

Almost perfect agreement (AC1 /AC2/ ICC > 0.80) was observed for all examined variables. Nominal and ordinal variables showed Gwet's agreement coefficients ranging from 0.85 (95% CI: 0.79-0.91) to 1.00 (95% CI: 1.00-1.00). For continuous and time variables there were detected high values of intraclass correlation coefficients (ICC) between 0.88 (95% CI: 0.83-0.91) and 1.00 (CI 95%: 1.00-1.00). While missing values in both the NTR and EPRs were in general negligeable, we found a substantial amount of missing registrations for a continuous "Base excess" in the NTR. For some of the time variables missing values both in the NTR and EPRs were high.

CONCLUSION

All tested variables in the Norwegian Trauma Registry displayed excellent agreement with the corresponding variables in electronic patient records. Variables in the registry that showed missing data need further examination.

Mortality after hospital admission for trauma in Norway: A retrospective observational national cohort study

BACKGROUND

National quality data for trauma care in Norway have not previously been reported. We have therefore assessed crude and risk-adjusted 30-day mortality in trauma cases after primary hospital admission on national and regional levels for 36 acute care hospitals and four regional trauma centres.

METHODS

All patients in the Norwegian Trauma Registry in 2015-2018 were included. Crude and risk-adjusted 30-day mortality was assessed for the total cohort and for severe injuries (Injury Severity Score ≥16), and individual and combined effects of health region, hospital level, and hospital size were studied.

RESULTS

28,415 trauma cases were included. Crude mortality was 3.1% for the total cohort and 14.5% for severe injuries, with no statistically significant difference between regions. Risk-adjusted survival was lower in acute care hospitals than in trauma centres (0.48 fewer excess survivors per 100 patients, P<0.0001), amongst severely injured patients in the Northern health region (4.80 fewer excess survivors per 100 patients, P = 0.004), and in hospitals with <100 trauma admissions per year (0.65 fewer excess survivors than in hospitals with ≥100 admissions, P = 0.01). However, the only statistically significant effects in a multivariable logistic case mix-adjusted descriptive model were hospital level and health region. Case-mix adjusted odds ratio for survival for severely injured patients directly admitted to a trauma centre vs. an acute care hospital was 2.04 (95% CI 1.04-4.00, P = 0.04), and if admitted in the Northern health region vs. all other health regions was 0.47 (95% CI 0.27-0.84, P = 0.01). The proportion of cases admitted directly to the regional trauma centre in the sparsely populated Northern health region was half of that in the other regions (18.4% vs. 37.6%, P<0.0001).

CONCLUSION

Differences in risk-adjusted survival for severe injuries can to a large extent be attributed to whether patients are directly admitted to a trauma centre. This should have implications for planning of transport capacity in remote areas.

Validation of the Swedish Trauma Registry (SweTrau)

PURPOSE

Validation of registries is important to ensure accuracy of data and registry-based research. This is often done by comparisons of the original registry data with other sources, e.g. another registry or a re-registration of data. Founded in 2011, the Swedish Trauma Registry (SweTrau) consists of variables based on international consensus (the Utstein Template of Trauma). This project aimed to perform the first validation of SweTrau.

METHODS

On-site re-registration was performed on randomly selected trauma patients and compared to the registration in SweTrau. Accuracy (exact agreement), correctness (exact agreement plus data within acceptable range), comparability (similarity with other registries), data completeness (1-missing data) and case completeness (1-missing cases) were deemed as either good ([Formula: see text] 85%), adequate (70-84%) or poor (< 70%). Correlation was determined as either excellent ([Formula: see text] 0.8), strong (0.6-0.79), moderate (0.4-0.59) or weak (< 0.4).

RESULTS

The data in SweTrau had good accuracy (85.8%), correctness (89.7%) and data completeness (88.5%), as well as strong or excellent correlation (87.5%). Case completeness was 44.3%, however, for NISS > 15 case completeness was 100%. Median time to registration was 4.5 months, with 84.2% registered one year after the trauma. The comparability showed an accordance with the Utstein Template of Trauma of almost 90%.

CONCLUSIONS

The validity of SweTrau is good, with high accuracy, correctness, data completeness and correlation. The data are comparable to other trauma registries using the Utstein Template of Trauma; however, timeliness and case completeness are areas of improvement.

Trauma Registry Data as a Policy-Making Tool: A Systematic Review on the Research Dimensions

Objective:

To review the research dimensions of trauma registry data on health policy making.

Methods:

PubMed and EMBASE were searched until July 2020. Keywords were used on the search process included Trauma, Injury, Registry and Research, which were searched by using appropriate search strategies. The included articles had to: 1. be extracted from data related to trauma registries; 2- be written in English; 3- define a time period and a patient population; 4- preferably have more details and policy recommendations; and 5- preferably have a discussion on how to improve diagnosis and treatment. The results obtained from the included studies were qualitatively analyzed using thematic synthesis and comparative tables.

Results:

In the primary round of search, 19559 studies were retrieved. According to PRISMA statement and also performing quality appraisal process, 30 studies were included in the final phase of analysis. In the final papers’ synthesis, 14 main research domains were extracted and classified in terms of the policy implication and research priority. The domains with the highest frequency were “The relationship between trauma registry data and hospital care protocols for trauma patients” and “The causes of Disability Adjusted Life Years (DALYs) due to trauma”.

Conclusion:

Using trauma registry data as a tool for policy-making could be helpful in several ways, namely increasing the quality of patient care, preventing injuries and decreasing their number, figuring out the details of socioeconomic status effects, and improving the quality of researches in practical ways. Also, follow-up of patients after trauma surgery as one of the positive effects of the trauma registry can be the focus of attention of policy-making bodies.

Accuracy of injury coding in a trauma registry

Introduction

Abbreviated Injury Scale has significant advantages over administrative coding systems for trauma analytics as it was developed specifically for injury, provides greater depth of characterisation of injury and has an integrated severity measure. It is used by trauma registries globally as it allows benchmarking between registries and is used to drive quality improvement. However, the consistency of scoring between individuals is not well understood. An audit was undertaken in six tertiary trauma centres in New Zealand to determine variation between AIS coders.

Methods

Each of six sites was audited by two experienced auditors. A random selection of case was identified in ISS categories 13–24, 25–44 and 45+. The case notes were pulled, and the auditors independently audited the notes,and then compared their results for a consensus result. The consensus result was then compared with the original coders.

Results

111 cases were audited. Coding concordance was found in 31% of cases. Of the 69% of cases where discordant coding was observed, the discordance was attributed to incorrect coding (49%), missed injuries (43%) and other reasons (7%). Head and chest body regions were associated with the greatest number, and largest differences in coding scores. The overall mean difference across all cases was an ISS score of 1.

Conclusions

The overall accuracy of data held in the New Zealand Trauma Registry (NZTR) is suitable for quality improvement and benchmarking purposes, but more work is needed to improve the accuracy of individual cases, particularly those with head/neck and chest injury. Standardised tools to ensure the accuracy of data in a trauma registry is a gap which needs to be addressed to maintain confidence in a contemporary trauma system.

New concept: "TARN friendly trauma reporting" (what radiologists say really does matter)

AIM

To establish if detailed review of trauma reports with reference to coding manual improved accuracy of ISS and to establish if demonstrated changes in coding affected performance and tariff payment.

MATERIALS AND METHODS

A study was undertaken which gathered data from 6 months across the five trusts with information on imaging undertaken, mechanism of injury (MOI), Injury Severity Score (ISS), and injury descriptors was included. Patients with ISS near to a best practice tariff boundary of 9 and 16 (5-8 and 11-15) then had their imaging reviewed by the Radiology Department with direct reference to the ISS coding manual. Injuries were then re-coded and ISS recalculated.

RESULTS

Over the 6-month period, 1,693 patients were admitted to the database from the five hospitals. One hundred and sixty-nine (9.9%) patients met the inclusion criteria for review. Thirty-five (20.7%) had a change in abbreviated (region specific) injury code, with 30 a change in the resultant ISS. Three had a decrease in ISS and 27 increased ISS with all 27 moving across an ISS best practice tariff and three moving across two payment tariff boundaries. With re-coding, there was a potential £15,000 of lost revenue from the major trauma centre (MTC) alone.

CONCLUSION

Reporting with reference to ISS description improves the accuracy of ISS significantly. Radiologists improving the descriptions of specific injury patterns and adopting 'Trauma Audit and Research Network friendly' reporting strategies may improve data accuracy, performance, and payment of best practice tariffs to hospitals.

Accuracy and reliability of injury coding in the national Dutch Trauma Registry

OBJECTIVE

Injury coding is well known for lack of completeness and accuracy. The objective of this study was to perform a nationwide assessment of accuracy and reliability on Abbreviated Injury Scale (AIS) coding by Dutch Trauma Registry (DTR) coders and to determine the effect on Injury Severity Score (ISS). Additionally, the coders' characteristics were surveyed.

METHODS

Three fictional trauma cases were presented to all Dutch trauma coders in a nationwide survey (response rate 69%). The coders were asked to extract and code the cases' injuries according to the AIS manual (version 2005, update 2008). Reference standard was set by three highly experienced coders. Summary statistics were used to describe the registered AIS codes and ISS distribution. The primary outcome measures were accuracy of injury coding and inter-rater agreement on AIS codes. Secondary outcome measures were characteristics of coders: profession, work setting, experience in injury coding and training level in injury coding.

RESULTS

The total number of different AIS codes used to describe 14 separate injuries in the three cases was 89. Mean accuracy per AIS code was 42.2% (range 2.4-92.7%). Mean accuracy on number of AIS codes was 23%. Overall inter-rater agreement per AIS code was 49.1% (range 2.4-92.7%). The number of assigned AIS codes varied between 0 and 18 per injury. Twenty-seven percentage of injuries were overlooked. ISS was correctly scored in 42.4%. In 31.7%, the AIS coding of the two more complex cases led to incorrect classification of the patient as ISS < 16 or ISS ≥ 16. Half (47%) of the coders had no (para)medical degree, 26% were working in level I trauma centers, 37% had less than 2 years of experience and 40% had no training in AIS coding.

CONCLUSIONS

Accuracy of and inter-rater agreement on AIS injury scoring by DTR coders is limited. This may in part be due to the heterogeneous backgrounds and training levels of the coders. As a result of the inconsistent coding, the number of major trauma patients in the DTR may be over- or underestimated. Conclusions based on DTR data should therefore be drawn with caution.