The Implications of Inaccuracy: Comparison of Coding in Heterotopic Ossification and Associated Trauma

Evaluation of the accuracy of diagnostic coding and clinical documentation for traumatic heterotopic ossification diagnoses in Western Australian hospitals

BACKGROUND

Traumatic heterotopic ossification (tHO) refers to the pathological formation of ectopic bone in soft tissues that can occur following burn, neurological ororthopaedic trauma. As completeness and accuracy of medical diagnostic coding can vary based on coding practices and depend on the institutional culture of clinical documentation, it is important to assess diagnostic coding in that local context. To the authors' knowledge, there is no prior study evaluating the accuracy of medical diagnostic coding or specificity of clinical documentation for tHO diagnoses across Western Australia (WA) trauma centres or across the full range of inciting injury and surgical events.

OBJECTIVE

To evaluate and compare the clinical documentation and the diagnostic accuracy of ICD-10-AM coding for tHO in trauma populations across 4 WA hospitals.

METHODS

A retrospective data search of the WA trauma database was conducted to identify patients with tHO admitted to WA hospitals following burn, neurological or orthopaedic trauma. Patient demographic and tHO diagnostic characteristics were assessed for all inpatient and outpatient tHO diagnoses. The frequency and distribution of M61 (HO-specific) and broader, musculoskeletal (non-specific) ICD-10-AM codes were evaluated for tHO cases in each trauma population.

RESULTS

HO-specific M61 ICD-10-AM codes failed to identify more than a third of true tHO cases, with a high prevalence of non-specific HO codes (19.4 %) and cases identified via manual chart review (25.4 %). The sensitivity of M61 codes for correctly diagnosing tHO after burn injury was 50 %. ROC analysis showed that M61 ICD-10-AM codes as a predictor of a true positive tHO diagnosis were a less than favourable method (AUC=0.731, 95 % CI=0.561-0.902, p = 0.012). Marked variability in clinical documentation for tHO was identified across the hospital network.

CONCLUSION

Coding inaccuracies may, in part, be influenced by insufficiencies in clinical documentation for tHO diagnoses, which may have implications for future research and patient care. Clinicians should consistently employ standardised clinical terminology from the point of care to increase the likelihood of accurate medical diagnostic coding for tHO diagnoses.

Identification of Risk Factors in the Development of Heterotopic Ossification After Primary Total Hip Arthroplasty

PURPOSE

Heterotopic ossification (HO) is a process by which bone forms abnormally in soft tissues. Known risk factors for developing HO include male sex, spinal cord injury, trauma, and surgery. We investigated additional risk factors in the development of HO after hip arthroplasty.

METHODS

We performed a retrospective review of electronic medical records of 4070 individuals who underwent hip arthroplasty from September 2010 to October 2019 at the University of California, San Francisco Hospital. Demographics, anthropometrics, medications, and comorbid conditions were used in logistic regression analysis to identify factors associated with the development of HO.

RESULTS

A total of 2541 patients underwent primary hip arthroplasty in the analyzed timeframe (46.04% men, mean age at procedure: 62.13 ± 13.29 years). The incidence of postsurgical HO was 3% (n = 80). A larger proportion of individuals who developed HO had underlying osteoporosis (P < 0.001), vitamin D deficiency (P < 0.001), spine disease (P < 0.001), type 1 or 2 diabetes (P < 0.001), amenorrhea (P = 0.037), postmenopausal status (P < 0.001), parathyroid disorders (P = 0.011), and history of pathologic fracture (P = 0.005). Significant predictors for HO development were Black/African American race [odds ratio (OR) 2.97, P = 0.005], preexisting osteoporosis (OR 2.72, P = 0.001), spine disease (OR 2.04, P = 0.036), and low estrogen states (OR 1.99, P = 0.025). In the overall group, 75.64% received perioperative nonsteroidal anti-inflammatory drugs (NSAIDs), which negatively correlated with HO formation (OR 0.39, P = 0.001).

CONCLUSIONS

We identified new factors potentially associated with an increased risk of developing HO after primary hip arthroplasty, including African American race, osteoporosis, and low estrogen states. These patients may benefit from HO prophylaxis, such as perioperative NSAIDs.

Patients Who Undergo Early Aseptic Revision TKA Within 90 Days of Surgery Have a High Risk of Re-revision and Infection at 2 Years: A Large-database Study

BACKGROUND

Early aseptic revision within 90 days after primary TKA is a devastating complication. The causes, complications, and rerevision risks of aseptic revision TKA performed during this period are poorly described.

QUESTIONS/PURPOSES

(1) What is the likelihood of re-revision within 2 years after early aseptic TKA revision within 90 days compared with that of a control group of patients undergoing primary TKA? (2) What are the indications for early aseptic TKA revision within 90 days? (3) What are the differences in revision risk between different indications for early aseptic revision TKA?

METHODS

Patients who underwent unilateral aseptic revision TKA within 90 days of the index procedure were identified in a national insurance claims database (PearlDiver Technologies) using administrative codes. The exclusion criteria comprised revision for infection, history of bilateral TKA, and age younger than 18 years. The PearlDiver database was selected for its large and geographically diverse patient base and the availability of outpatient follow-up data that are unavailable in other databases focused on inpatient care. A total of 481 patients met criteria for early aseptic revision TKA, with 14% (67) loss to follow-up at 2 years. This final cohort of 414 patients was compared with a control group of patients who underwent primary TKA without revision within 90 days. For the control group, 137,661 patients underwent primary TKA without early revision, with 13% (18,138) loss to follow-up at 2 years. Among these patients, 414 controls were matched using a one-to-one propensity score method; no differences in age, gender, and Charlson comorbidity index score were observed between the groups. Indications for initial revision and 2-year re-revision were recorded. The Kaplan-Meier method was used to assess survival between the early revision and control groups.

RESULTS

Two-year survivorship free from additional revision surgery was lower in the early aseptic revision cohort compared with the control (78% [95% confidence interval 77% to 79%] versus 98% [95% CI 96% to 99%]; p < 0.001). Among early revisions, 10% (43 of 414) of the patients underwent re-revision for periprosthetic infection with an antibiotic spacer within 2 years. The reasons for early aseptic revision TKA were instability/dislocation (37% [153 of 414]), periprosthetic fracture (23% [96 of 414]), aseptic loosening (23% [95 of 414]), pain (11% [45 of 414]), and arthrofibrosis (6% [25 of 414]). Early revision for pain was associated with higher odds of re-revision than early revisions performed for other all other reasons (44% [20 of 45] versus 29% [100 of 344]; odds ratio 2.0 [95% CI 1.0 to 3.7]; p = 0.04).

CONCLUSION

Acute early aseptic revision TKA carries a high risk of re-revision at 2 years and a high risk of subsequent periprosthetic joint infection. Patients who undergo an early revision should be carefully counseled regarding the very high risk of repeat revision and discouraged from having early revision unless the indications are absolutely clear and compelling. Early aseptic revision for pain alone carries an unacceptably high risk of repeat revision and should not be performed. Adjunctive measures for infection prophylaxis should be strongly considered. Specific interventions to reduce surgical complications in this subset of patients have not been adequately studied; additional investigation of strategies to minimize the risk of reoperation or infection is warranted.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Bias of Inaccurate Disease Mentions in Electronic Health Record-based Phenotyping

OBJECTIVES

Electronic health record (EHR)-based phenotyping is an automated technique for identifying patients diagnosed with a particular disease using EHR data. However, EHR-based phenotyping has difficulties in achieving satisfactorily high performance because clinical notes include disease mentions that ultimately signify something other than the patient's diagnosis (such as differential diagnosis or screening). Our objective is to quantify the influence of such disease mentions on EHR-based phenotyping performance.

METHODS

Physicians manually reviewed whether the disease mentions indicated the patients' diseases in 487,300 clinical notes of 4,430 patients. Particular focus was placed on disease mentions that did not signify the patient's diagnosis even though they did not have any syntactic modifier or indicator in the same sentences. Patients were then classified according to whether their clinical notes included such disease mentions.

RESULTS

Among the patients whose clinical notes included disease mentions without any modifier or indicator, the proportion of patients whose disease mentions signified the patients' diagnosis was 78.1% (on average). This value can be interpreted as the bias of disease mentions that did not signify the patient's diagnosis on the precision of EHR-based phenotyping by extracting disease mentions from clinical notes.

CONCLUSION

This study quantified the bias occurred owing to disease mentions that incorrectly signify a patient's diagnosis in the value of precision of EHR-based phenotyping from four dataset types. The results of this study will help researchers in diverse research environments with different available data types.

An Interactive Multimodality Curriculum Teaching Medicine Residents About Oncologic Documentation and Billing

Introduction

Physicians recognize the importance of clinical documentation for accuracy of coding and billing, but it is emphasized little in residency curricula, with an even smaller emphasis on oncology-specific documentation. We developed an educational curriculum to teach residents about clinical documentation for cancer patients. Our tool kit includes didactics, simulated history and physical (H&P) documentation, and personal feedback.

Methods

A preintervention survey was first administered to gauge baseline knowledge. A simulated H&P was developed that required participants to complete their own assessment and plan. We delivered a 25-minute lecture regarding billing and coding along with documentation tips and tricks specific to hematology/oncology. Thereafter, we handed out a second H&P, and participants had to once again complete their own assessment and plan. These H&Ps were graded by three reviewers using a rubric. We then gave residents personalized feedback using the above data and administered a postintervention survey.

Results

The postintervention survey revealed that 100% of the residents surveyed found this activity helpful, 83% noted that further knowledge of diagnosis codes was helpful to their learning, 100% noted that that this activity taught them to improve documentation, 91% said they were more likely to use cancer-specific diagnoses, and 91% said they would benefit from direct feedback-based education.

Discussion

Didactic and formal education is more effective when combined with hands-on examples and direct personalized feedback.

Leveraging healthcare utilization to explore outcomes from musculoskeletal disorders: methodology for defining relevant variables from a health services data repository

Background

Large healthcare databases, with their ability to collect many variables from daily medical practice, greatly enable health services research. These longitudinal databases provide large cohorts and longitudinal time frames, allowing for highly pragmatic assessment of healthcare delivery. The purpose of this paper is to discuss the methodology related to the use of the United States Military Health System Data Repository (MDR) for longitudinal assessment of musculoskeletal clinical outcomes, as well as address challenges of using this data for outcomes research.

Methods

The Military Health System manages care for approximately 10 million beneficiaries worldwide. Multiple data sources pour into the MDR from multiple levels of care (inpatient, outpatient, military or civilian facility, combat theater, etc.) at the individual patient level. To provide meaningful and descriptive coding for longitudinal analysis, specific coding for timing and type of care, procedures, medications, and provider type must be performed. Assumptions often made in clinical trials do not apply to these cohorts, requiring additional steps in data preparation to reduce risk of bias. The MDR has a robust system in place to validate the quality and accuracy of its data, reducing risk of analytic error. Details for making this data suitable for analysis of longitudinal orthopaedic outcomes are provided.

Results

Although some limitations exist, proper preparation and understanding of the data can limit bias, and allow for robust and meaningful analyses. There is the potential for strong precision, as well as the ability to collect a wide range of variables in very large groups of patients otherwise not captured in traditional clinical trials. This approach contributes to the improved understanding of the accessibility, quality, and cost of care for those with orthopaedic conditions.

Conclusion

The MDR provides a robust pool of longitudinal healthcare data at the person-level. The benefits of using the MDR database appear to outweigh the limitations.

Prevalence of fibrodysplasia ossificans progressiva (FOP) in France: an estimate based on a record linkage of two national databases

Background

Fibrodysplasia ossificans progressiva (FOP) is a rare, severely disabling, and life-shortening genetic disorder that causes the formation of heterotopic bone within soft connective tissue. Previous studies found that the FOP prevalence was about one in every two million lives. The aim of this study is to estimate the FOP prevalence in France by probabilistic record-linkage of 2 national databases: 1) the PMSI (Programme de médicalisation des systèmes d’information), an administrative database that records all hospitalization activities in France and 2) CEMARA, a registry database developed by the French Centres of Reference for Rare Diseases.

Results

Using a capture-recapture methodology to adjust the crude number of patients identified in both data sources, 89 FOP patients were identified, which results in a prevalence of 1.36 per million inhabitants (CI95% = [1.10; 1.68]). FOP patients’ mean age was 25 years, only 14.9% were above 40 years, and 53% of them were males. The first symptoms – beside toe malformations- occurred after birth for 97.3% of them. Mean age at identified symptoms was 7 years and above 18 years for only 6.9% of patients. Mean age at diagnosis was 10 years, and above 18 years for 14.9% of the patients. FOP patients were distributed across France.

Conclusions

Despite the challenge of ascertaining patients with rare diseases, we report a much higher prevalence of FOP in France than in previous studies elsewhere. We suggest that efforts to identify patients and confirm the diagnosis of FOP should be reinforced and extended at both national and European level.