Accuracy of ICD-10-CM encounter diagnoses from health records for identifying self-harm events

OBJECTIVE

Assess the accuracy of ICD-10-CM coding of self-harm injuries and poisonings to identify self-harm events.

MATERIALS AND METHODS

In 7 integrated health systems, records data identified patients reporting frequent suicidal ideation. Records then identified subsequent ICD-10-CM injury and poisoning codes indicating self-harm as well as selected codes in 3 categories where uncoded self-harm events might be found: injuries and poisonings coded as undetermined intent, those coded accidental, and injuries with no coding of intent. For injury and poisoning encounters with diagnoses in those 4 groups, relevant clinical text was extracted from records and assessed by a blinded panel regarding documentation of self-harm intent.

RESULTS

Diagnostic codes selected for review include all codes for self-harm, 43 codes for undetermined intent, 26 codes for accidental intent, and 46 codes for injuries without coding of intent. Clinical text was available for review for 285 events originally coded as self-harm, 85 coded as undetermined intent, 302 coded as accidents, and 438 injury events with no coding of intent. Blinded review of full-text clinical records found documentation of self-harm intent in 254 (89.1%) of those originally coded as self-harm, 24 (28.2%) of those coded as undetermined, 24 (7.9%) of those coded as accidental, and 48 (11.0%) of those without coding of intent.

CONCLUSIONS

Among patients at high risk, nearly 90% of injuries and poisonings with ICD-10-CM coding of self-harm have documentation of self-harm intent. Reliance on ICD-10-CM coding of intent to identify self-harm would fail to include a small proportion of true self-harm events.

Concordance between patient-centered and adaptive behavior outcome measures after applied behavior analysis for autism

BACKGROUND

Applied behavior analysis (ABA) is an evidence-based approach to autism spectrum disorder that has been shown in clinical trials to improve child functional status. There is substantial focus in ABA on setting and tracking individualized goals that are patient-centered, but limited research on how to measure progress on such patient-centered outcomes.

PURPOSE

The purpose of this investigation was to assess concordance between patient-centered and standard outcome measures of treatment progress in a real-world clinical sample of children receiving ABA for autism spectrum disorder.

METHODS

This observational study used a clinical sample of children ages 3 to 16 years (N = 154) who received 24 months of ABA from an integrated health system. Concordance between three outcome measures after ABA was assessed using a correlation matrix: (1) patient-centered measures of progress on individualized treatment goals, (2) caregiver-centered measure of progress on treatment participation goals, and (3) the Vineland Adaptive Behavior Scales adaptive behavior composite.

RESULTS

There was limited concordance among measures at both 12 and 24 months of ABA. None of the patient-centered measures showed significant positive correlation with adaptive behavior composite difference scores at either 12 or 24 months, nor did the caregiver measure. The percentage of children achieving clinically meaningful gain on patient-centered goal measures increased between 12 and 24 months of ABA, while the percentage of children achieving clinically meaningful gains in adaptive behavior declined during the same time period.

CONCLUSIONS

In a health system implementation of ABA, there was limited concordance between patient-centered and standard measures of clinically meaningful treatment progress for children with ASD. Clinicians should have ongoing dialogue with patients and parents/caregivers to ensure that interventions for ASD are resulting in progress towards outcomes that are meaningful to patients and families.

Parent intentions to vaccinate children with autism spectrum disorder against COVID-19

PURPOSE

The purpose of this study was to investigate associations between parent vaccine confidence and intention to have their child with autism vaccinated against COVID-19.

DESIGN AND METHODS

A cross-sectional, web-based survey was conducted from May to July 2021 with parents of children with autism spectrum disorder (N = 322) who were members of an integrated healthcare system in Southern California.

RESULTS

Approximately 35% of parents intended to vaccinate their child against COVID-19. In adjusted models, positive vaccine beliefs-but not belief in vaccine harm, healthcare provider trust, or parent vaccination status-were associated with intention to vaccinate.

CONCLUSIONS

Though parents usually trust recommendations from pediatric healthcare providers to make decisions about their child's health, these findings suggest that relying on trusted relationships alone may not be sufficient when discussing COVID-19 vaccines and that additional education to bolster vaccine confidence may be needed.

PRACTICE IMPLICATIONS

Pediatric healthcare providers should reinforce the benefits of vaccines for parents who are undecided about COVID-19 vaccines for their children and provide education and evidence-based recommendations to parents who hold erroneous vaccine beliefs about risks, benefits, and current evidence, especially those related to autism.

Patient Outcomes After Applied Behavior Analysis for Autism Spectrum Disorder

OBJECTIVES

The purpose of this study was to examine patterns of service receipt and patient outcomes for children receiving applied behavior analysis (ABA) for autism spectrum disorder (ASD) in an integrated health care system in which commercially insured children were covered by a state autism mandate.

METHODS

This retrospective, observational study used a random sample of children with ASD (3-17 yrs) who were members of a large integrated health care system in Southern California and referred for ABA between January 2016 and November 2018. From the 4145 children referred, a random stratified sample of 334 was selected to extract data from clinical reports over 24 months of services. The primary outcome measures were time in ABA and child adaptive behavior.

RESULTS

Thirteen percent of the sample never received ABA after referral. Of those who were referred for ABA, 66% initiated ABA and remained in services for 12 months, whereas less than half (46%) remained in services for 24 months. Having a history of special education was associated with longer time spent in ABA, whereas having a single parent was associated with discontinuation of ABA. A minority of children received a full ABA dose (28%), but the lowest functioning children still experienced clinically significant adaptive behavior gains after 24 months of ABA (p = 0.02).

CONCLUSION

In a health system implementation of ABA for children with ASD, there were high rates of ABA discontinuation and low ABA dosing. These challenges may diminish the potential benefits of ABA, even in a context in which there is mandated commercial insurance coverage.

A framework to aid adoption of automated rehabilitation devices into clinical practice: synthesising and Interpreting Language for Clinical Kinematics (SILCK)

The Synthesising and Interpreting Language for Clinical Kinematics (SILCK) is an informatic framework for developing software to control automated rehabilitation devices. It aids adoption of devices into rehabilitation practice, by bridging the gap between clinical practice and internal device operation. SILCK defines data entities and processes for capturing clinical observations of patients and their rehabilitation goals in formats which can be used to direct the tailoring of device parameters to the individual patient's needs.

A pilot study of scoliosis assessment using radiation free surface topography in children with GMFCS IV and V cerebral palsy

BACKGROUND

Prevalence of scoliosis in cerebral palsy (CP) parallels the extent of neurological impairment and causes significant morbidity. Monitoring is important but requires regular radiological investigation. Surface topography provides a non-radiological approach to scoliosis monitoring.

AIM

To evaluate validity, reproducibility and feasibility of Quantec(®) scans to monitor scoliosis in children with severe CP.

METHODS

Twenty non-ambulant children with CP, Gross Motor Function Classification System (GMFCS) grade IV/V had clinical, radiological and Quantec spinal assessment. The children were supported during scans using a seating system specifically designed for this study. Validity was assessed by comparing Quantec (Q) angle with gold standard (Cobb angle), reproducibility analysed using Bland-Altman plots and feasibility assessed using a questionnaire.

RESULTS

Prevalence of scoliosis on radiological examination was 65%. Of these children, 85% had curves with Cobb angle less than 28°. Quantec scanning was feasible with appropriate postural support. Mean (and standard deviation) for differences between Cobb and Quantec (Q) angle were 0.02° (6.2°) and for Quantec inter-observer variability were 0.5° (5.8°).

CONCLUSIONS

Quantec scanning was feasible, reproducible and had good validity when compared with Cobb angle in a supportive seating system. To consolidate these findings a further study needs to be undertaken with larger number of children with Cobb angles between 25° and 45°.

A novel robotic system for quantifying arm kinematics and kinetics: description and evaluation in therapist-assisted passive arm movements post-stroke

We developed a system for quantitatively measuring arm movement. Our approach provides a method to simultaneously capture upper limb kinetic and kinematic data during assisted passive arm movements. Data are analysed with respect to Cartesian and upper limb coordinate systems to obtain upper limb joint angles and torques. We undertook an evaluation of the system in participants with stroke to show the feasibility of this approach. During rehabilitation after stroke, one aspect of treatment includes the physiotherapist applying assistive forces to move the impaired arm of the patient who remains passive. There is a dearth of published data on the relationship between upper limb kinematics and the underlying forces (kinetics) in this mode of physiotherapy treatment. Such quantitative data are crucial in facilitating research into therapy practice, for example by measuring variation in practice and determining dosage. An experienced therapist prescribed passive movements tailored to the needs of 16 participants with stroke (41-81 years) with a range of anthropometric sizes and motor impairments. Our novel measurement tool recorded kinematic and kinetic data at 100 Hz for 6-11 movements per participant. The kinetic data show that the majority of movements fall within upper limits of 36.7 N in shoulder elevation, 22.4N in shoulder protraction, 4.6 Nm in shoulder abduction, 12.8 Nm in shoulder flexion, 2.4 Nm in shoulder rotation and 5.5 Nm in elbow flexion. These data show the potential of this system to better understand arm movement, in particular to objectively evaluate physical therapy treatments and support development of robotic devices to facilitate upper limb rehabilitation.

A double-blind randomised placebo-controlled evaluation of three doses of botulinum toxin type A (Dysport) in the treatment of spastic equinovarus deformity after stroke

BACKGROUND/OBJECTIVES

Calf muscle hypertonicity following stroke may impair walking rehabilitation. The aim of this study was to assess botulinum toxin (Dysport) in post-stroke calf spasticity.

METHODS

A prospective, multicentre, double-blind, placebo-controlled, dose-ranging study was performed to evaluate dysport at 500, 1,000 or 1,500 units in 234 stroke patients. They were assessed at 4-week intervals over 12 weeks.

RESULTS

The primary outcome measure, 2-min walking distance and stepping rate increased significantly in each group (p < 0.05, paired test), but there was no significant difference between groups (including placebo). Following dysport treatment, there were small but significant (p = 0.0002-0.0188) improvements in calf spasticity, limb pain, and a reduction in the use of walking aids, compared to placebo. Investigators' and patients' assessments of overall benefit suggested an advantage for dysport over placebo, but this was not significant. Sixty-eight patients reported 130 adverse events, with similar numbers in each group. The few severe events recorded were not considered to be treatment-related.

CONCLUSION

Dysport resulted in a significant reduction in muscle tone, limb pain and dependence on walking aids. The greatest benefits were in patients receiving dysport 1,500 units, but 1,000 units also had significant effects. Dysport 500 units resulted in some improvements. Since few adverse events were reported, this therapy is considered safe and may be a useful treatment in post-stroke rehabilitation of the leg. Possible reasons why functional improvements in gait parameters were not observed are also discussed.

Botulinum toxin (Dysport) treatment of hip adductor spasticity in multiple sclerosis: a prospective, randomised, double blind, placebo controlled, dose ranging study

OBJECTIVE

To define a safe and effective dose of Dysport for treating hip adductor spasticity.

METHODS

Patients with definite or probable multiple sclerosis, and disabling spasticity affecting the hip adductor muscles of both legs, were randomised to one of four treatment groups. Dysport (500, 1000, or 1500 Units), or placebo was administered by intramuscular injection to these muscles. Patients were assessed at entry, and 2, 4 (primary analysis time-point), 8, and 12 weeks post-treatment.

RESULTS

A total of 74 patients were recruited. Treatment groups were generally well matched at entry. The primary efficacy variables-passive hip abduction and distance between the knees-improved for all groups. The improvement in distance between the knees for the 1500 Unit group was significantly greater than placebo (p = 0.02). Spasm frequency was reduced in all groups, but muscle tone was reduced in the Dysport groups only. Pain was reduced in all groups, but improvements in hygiene scores were evident only in the 1000 Unit and 1500 Unit groups. Duration of benefit was significantly longer than placebo for all Dysport groups (p<0.05). Adverse events were reported by 32/58 (55%) Dysport patients, and by 10/16 (63%) placebo patients. Compared with the two lower dose groups, twice as many adverse events were reported by the 1500 Unit group (2.7/patient). The incidence of muscle weakness was higher for the 1500 Unit group (36%) than for placebo (6%). The response to treatment was considered positive by two thirds of the patients in the 500 Unit group, and by about half the patients in the other groups.

CONCLUSION

Dysport reduced the degree of hip adductor spasticity associated with multiple sclerosis, and this benefit was evident despite the concomitant use of oral antispasticity medication and analgesics. Although evidence for a dose response effect was not statistically significant, there was a clear trend towards greater efficacy and duration of effect with higher doses of Dysport. Dysport treatment was well tolerated, with no major side effects seen at doses up to 1500 Units. The optimal dose for hip adductor spasticity seems to be 500-1000 Units, divided between both legs.

Life-threatening transient neonatal Behçet's disease

This case report describes transient neonatal Behçet's disease, with life-threatening complications in the neonate. Male Baby R developed blood-streaked diarrhoea 5 days after birth, followed by recurrent severe scarring orogenital ulceration and vasculitic skin lesions. In this sixth week of life, he developed stridor leading to a respiratory arrest and necessitating assisted ventilation. No infective cause was isolated. Baby R responded well to i.v. and subsequent oral steroid therapy. At 8 weeks old he had fully recovered and remains well. Baby R's mother was not previously known to have Behçet's disease. During the pregnancy, she began to suffer orogenital ulceration, associated with skin lesions typical of Behçet's disease. Mild orogenital ulceration has become recurrent.

Recent advances in rehabilitation medicine

Rehabilitation is aimed at minimising the disadvantage experienced by an individual as a result of functional impairment or disability following disease. It also addresses the impact of the social and environmental consequences of disease. Rehabilitation medicine is a new specialty although the concept of rehabilitation is not. Previously this work was undertaken within the fields of rheumatology, physical medicine, neurology, and orthopaedic, general medical and limb fitting services. In some patients, primarily those with neurological and musculoskeletal disease, the interaction of impairments with social and environmental dimensions can be complex. Effective management requires coordination between the patient, carers, and the medical, therapy, nursing, psychology and social services. The management of patients with complex disabilities is undergoing change with the introduction of new treatments, awareness of needs of patients and carers, and new models of care. This conference, entitled 'Medical priorities in the rehabilitation of adults with complex disabilities' given at the Royal College of Physicians on 2 February 1995, reviewed these changes. It dealt with medical priorities in rehabilitation for patients with specific diseases, and recent advances in areas pertinent to rehabilitation medicine.

Behçet's disease

The reliability and ease of use of any activity form has to be balanced against the content validity of the questions being asked. Clinical experience over several years suggests that presence of a high disease activity score is consistent both with the clinician's and patient's overall impression of disease activity. If the onset of the more serious manifestations can be predicted by more readily measured symptoms such as oral and genital ulceration, skin lesions, arthritis and superficial thrombophlebitis, then these organ system subscores could be expanded to provide a more accurate representation of activity. Other organ systems such as auditory system may also provide a measure of disease activity. For the purpose of clinical trials it is likely that if treatment is targeted at a specific organ system then a more comprehensive measure of activity within that organ system would have to be used (e.g. the role of thalidomide in oral ulceration) (Revuz et al, 1990). This would require the use of a form which measured many facets of oral ulceration (duration of ulcers, number of ulcers, size of ulcers, number of crops of ulcers, site of ulcers, etc). However it is recommended that such a form should be used in conjunction with a validated general disease activity form to alert the clinician conducting any trials of the advantageous or deleterious effects of the trial drug on other organ systems.