Defining the emergency general surgery patient population in the era of ICD-10 : Evaluating an established crosswalk from ICD-9 to ICD-10 diagnosis codes

INTRODUCTION

In 2015, the United States moved from the International Classification of Diseases, Ninth Revision ( ICD-9 ), to the International Classification of Diseases, Tenth Revision ( ICD-10 ), coding system. The American Association for the Surgery of Trauma Committee on Severity Assessment and Patient Outcomes previously established a list of ICD-9 diagnoses to define the field of emergency general surgery (EGS). This study evaluates the general equivalence mapping (GEM) crosswalk to generate an equivalent list of ICD-10 -coded EGS diagnoses.

METHODS

The GEM was used to generate a list of ICD-10 codes corresponding to the American Association for the Surgery of Trauma ICD-9 EGS diagnosis codes. These individual ICD-9 and ICD-10 codes were aggregated by surgical area and diagnosis groups. The volume of patients admitted with these diagnoses in the National Inpatient Sample in the ICD-9 era (2013-2014) was compared with the ICD-10 volumes to generate observed to expected ratios. The crosswalk was manually reviewed to identify the causes of discrepancies between the ICD-9 and ICD-10 lists.

RESULTS

There were 485 ICD-9 codes, across 89 diagnosis categories and 11 surgical areas, which mapped to 1,206 unique ICD-10 codes. A total of 196 (40%) ICD-9 codes have an exact one-to-one match with an ICD-10 code. The median observed to expected ratio among the diagnosis groups for a primary diagnosis was 0.98 (interquartile range, 0.82-1.12). There were five key issues identified with the ability of the GEM to crosswalk ICD-9 EGS diagnoses to ICD-10 : (1) changes in admission volumes, (2) loss of necessary modifiers, (3) lack of specific ICD-10 code, (4) mapping to a different condition, and (5) change in coding nomenclature.

CONCLUSION

The GEM provides a reasonable crosswalk for researchers and others to use when attempting to identify EGS patients in with ICD-10 diagnosis codes. However, we identify key issues and deficiencies, which must be accounted for to create an accurate patient cohort. This is essential for ensuring the validity of policy, quality improvement, and clinical research work anchored in ICD-10 coded data.

LEVEL OF EVIDENCE

Diagnostic Test/Criteria; Level III.

The Trauma Dyad: The Role of Informal Caregivers for Older Adults After Traumatic Injury

OBJECTIVE

To investigate the association between higher injury severity and increased informal caregiving received by injured older adults.

SUMMARY OF BACKGROUND DATA

Injured older adults experience high rates of functional decline and disability after hospitalization. Little is known about the scope of caregiving received post-discharge, particularly from informal caregivers such as family.

METHODS

We used the National Health and Aging Trends Study 2011 to 2018 linked to Medicare claims to identify adults ≥65 with hospital admission for traumatic injury and a National Health and Aging Trends Study interview within 12 months pre- and post-trauma. Injury severity was assessed using the injury severity score (ISS, low 0-9; moderate 10-15; severe 16-75). Patients reported the types and hours of formal and informal help received and any unmet care needs. Multi variable logistic regression models examined the association between ISS and increase in informal caregiving hours after discharge.

RESULTS

We identified 430 trauma patients. Most were female (67.7%), non-Hispanic White (83.4%) and half were frail. The most common mechanism of injury was fall (80.8%) and median injury severity was low (ISS = 9). Those reporting receiving help with any activity increased post-trauma (49.0% to 72.4%, P < 0.01), and unmet needs nearly doubled (22.8% to 43.0%, P < 0.01). Patients had a median of 2 caregivers and most (75.6%) were informal, often family members. Median weekly hours of care received pre- versus post-injury increased from 8 to 14 (P < 0.01). ISS did not independently predict increase in caregiving hours; pre-trauma frailty predicted an increase in hours ≥8 per week.

CONCLUSIONS

Injured older adults reported high baseline care needs which increased significantly after hospital discharge and were mostly met by informal caregivers. Injury was associated with increased need for assistance and unmet needs regardless of injury severity. These results can help set expectations for caregivers and facilitate post-acute care transitions.

How to make PROMs work: qualitative insights from leaders at United States hospitals with successful PROMs programs

PURPOSE

Elucidate facilitators, barriers, and key lessons learned regarding the implementation of system-wide clinical patient-reported outcome measure (PROM) programs among United States (US) healthcare leaders.

METHODS

We conducted semi-structured interviews with 35 US healthcare leaders, including chief-level executives, data directors, PROM directors, and department chairs involved in PROM implementation across seven diverse healthcare systems from February to June 2020. Transcripts were coded, evaluated for qualitative themes, and categorized according to the consolidated framework for implementation research (CFIR).

RESULTS

According to US hospital leaders with experience in existing clinical PROM programs, there are facilitators and barriers to implementation success in each CFIR domain. Allowing clinicians to select PROM measures and ensuring a user-friendly data platform (intervention); adapting data collection to patient home environments (outer setting); informing clinicians of the multi-faceted use of PROM data for research, clinical care, and business (inner setting); implementing PROM education earlier into clinician training (characteristics of individuals); and establishing specialty-agnostic PROM implementation teams (process) were among key facilitators to implementation success.

CONCLUSION

Leaders of geographically and clinically diverse PROM programs in the US identify common themes that facilitate successful implementation. Drivers of success depend on factors within and outside the clinical environment. These findings may serve to guide both establishing new PROM programs and refining existing PROM programs.

Reassessing the July Effect: 30 Years of Evidence Show No Difference in Outcomes

OBJECTIVE

The aim of this study was to critically evaluate whether admission at the beginning versus end of the academic year is associated with increased risk of major adverse outcomes.

SUMMARY BACKGROUND DATA

The hypothesis that the arrival of new residents and fellows is associated with increases in adverse patient outcomes has been the subject of numerous research studies since 1989. Methods: We conducted a systematic review and random-effects meta-analysis of July Effect studies published before December 20, 2019, looking for differences in mortality, major morbidity, and readmission. Given a paucity of studies reporting readmission, we further analyzed 7 years of data from the Nationwide Readmissions Database to assess for differences in 30-day readmission for US patients admitted to urban teaching versus nonteach-ing hospitals with 3 common medical (acute myocardial infarction, acute ischemic stroke, and pneumonia) and 4 surgical (elective coronary artery bypass graft surgery, elective colectomy, craniotomy, and hip fracture) conditions using risk-adjusted logistic difference-in-difference regression.

RESULTS

A total of 113 studies met inclusion criteria; 92 (81.4%) reported no evidence of a July Effect. Among the remaining studies, results were mixed and commonly pointed toward system-level discrepancies in efficiency. Metaanalyses of mortality [odds ratio (95% confidence interval): 1.01 (0.98-1.05)] and major morbidity [1.01 (0.99-1.04)] demonstrated no evidence of a July Effect, no differences between specialties or countries, and no change in the effect over time. A total of 5.98 million patient encounters were assessed for readmission. No evidence of a July Effect on readmission was found for any of the 7 conditions.

CONCLUSION

The preponderance of negative results over the past 30 years suggests that it might be time to reconsider the need for similarly-themed studies and instead focus on system-level factors to improve hospital efficiency and optimize patient outcomes.

Impetus of US hospital leaders to invest in patient-reported outcome measures (PROMs): a qualitative study

OBJECTIVES

Though hospital leaders across the USA have invested significant resources in collection of patient-reported outcome measures (PROMs), there are very limited data on the impetus for hospital leadership to establish PROM programmes. In this qualitative study, we identify the drivers and motivators of PROM collection among hospital leaders in the USA.

DESIGN

Exploratory qualitative study.

SETTING

Thirty-seven hospital leaders representing seven different institutions with successful PROMs programs across twenty US states.

METHODS

Semistructured interviews conducted with hospital leaders. Transcripts were analysed using thematic analysis.

RESULTS

Leaders strongly believe that collecting PROMs is the 'right thing to do' and that the culture of the institution plays an important role in enabling PROMs. The study participants often believe that their institutions deliver superior care and that PROMs can be used to demonstrate the value of their services to payors and patients. Direct financial incentives are relatively weak motivators for collection of PROMs. Most hospital leaders have reservations about using PROMs in their current state as a meaningful performance metric.

CONCLUSION

These findings suggest that hospital leaders feel a strong moral imperative to collect PROMs, which is also supported by the culture of their institution. Although PROMs are used in negotiations with payors, direct financial return on investment is not a strong driver for the collection of PROMs. Understanding why leaders of major healthcare institutions invest in PROMs is critical to understanding the role that PROMs play in the US healthcare system.

The impact of the Affordable Care Act's medicaid expansion on patients admitted for burns: An analysis of national data

INTRODUCTION

The first states began implementing the Medicaid expansion provisions of the Patient Protection and Affordable Care Act (ACA) in 2014. Studies have yet to address its impact on burn patients.

METHODS

Burn patients in geographic regions that expanded Medicaid coverage were compared to patients in regions that did not expand Medicaid before and after implementation of the ACA using bivariate statistics and a difference-in-differences model. A multivariable logistic regression was used to identify factors associated with having Medicaid insurance. The primary outcome of this study was the rate of Medicaid insurance.

RESULTS

Of 25,331 discharges, we found greater increases in Medicaid coverage after the ACA in the Medicaid expander regions (23.4-40.2%) compared to the non-expander regions (18.5-20.1%). The difference-in-differences estimate between the expander and non-expander regions was 0.15 (95% CI: 0.11-0.18, p < 0.001). Patients admitted in expander regions were more likely to be insured by Medicaid (OR 1.57 [95%CI 1.21-2.05]), as were patients of Black race (OR 1.25 [95%CI 1.19-1.32), Hispanic ethnicity (OR 1.29 [95%CI 1.14-1.46]), and female sex (OR 1.59 [95%CI 1.11-2.27]). We also found a significant interaction between time period (pre-ACA/post-ACA) and expander region location (OR 2.10 [95%CI 1.67-2.62]).

CONCLUSIONS

The Medicaid expansion provision of the ACA led to increased Medicaid coverage among burn patients which was significantly higher in areas with widespread implementation of the expansion.

Understanding the role of informal caregivers in postoperative care transitions for older patients

BACKGROUND

Older adults may have new care needs and functional limitations after surgery. Many rely on informal caregivers (unpaid family or friends) after discharge but the extent of informal support is unknown. We sought to examine the role of informal postoperative caregiving on transitions of care for older adults undergoing routine surgical procedures.

MATERIALS AND METHODS

We performed a retrospective cohort study using ACS NSQIP Geriatric Pilot Project data, 2014-2018. Patients were ≥65 years and underwent an inpatient surgical procedure. Patients who lived at home alone were compared with those who lived with support from informal caregivers (family and/or friends). Primary outcomes were discharge destination (home vs. post-acute care) and readmission within 30 days. Multivariable logistic regression was used to determine the association between support at home, discharge destination, and readmission.

RESULTS

Of 18,494 patients, 25% lived alone before surgery. There was no difference in loss of independence (decline in functional status or new use of mobility aid) after surgery between patients who lived alone or with others (18.7% vs. 19.5%, p = 0.24). Nevertheless, twice as many patients who lived alone were discharged to a non-home location (10.2% vs. 5.1%; OR: 2.24, CI: 1.93-2.56). Patients who lived alone and were discharged home with new informal caregivers had increased odds of readmission (OR: 1.43, CI: 1.09-1.86).

CONCLUSION

Living alone independently predicts discharge to post-acute care, and patients who received new informal caregiver support at home have higher odds of readmission. These findings highlight opportunities to improve discharge planning and care.

Quality Indicators in Surgical Palliative Care: A Systematic Review

CONTEXT

Defining high quality palliative care in seriously ill surgical patients is essential to provide patient-centered surgical care. Quality indicators specifically for seriously ill surgical patients are necessary in order to integrate palliative care into existing surgical quality improvement programs.

OBJECTIVES

To identify existing quality indicators that measure palliative care delivery in seriously ill surgical patients, characterize their development, and assess their methodological quality.

METHODS

A PRISMA-guided systematic review included studies that reported on the development process and characteristics of palliative care quality indicators and guidelines in adult surgical patients. Relevant measures were categorized into the previously defined National Consensus Project domains of palliative care and the Donabedian quality framework, and assessed for methodological quality.

RESULTS

There were 263 unique measures identified from 26 studies, of which 70% were process measures. Indicators addressing Care of the Patient Near the End of Life (31.5%) and Physical Aspects of Care (20.8%) were the most common. Indicators addressing Spiritual (2.6%) and Cultural Aspects of Care (1.2%) were the least common. Methodological quality varied widely across studies. Although most studies defined a purpose for the indicators and used scientific evidence, many studies lacked input from target populations and few had discussed the practical application of indicators.

CONCLUSION

This review was a key step that informed efforts to develop quality indicators for seriously ill surgical patients. Few indicators addressed non-physical aspects of suffering and no indicators were identified addressing palliative surgery. Future attention is needed toward the development and practical application of palliative care quality indicators in surgical patients.

Socially conscious surgical care must prioritize older adults

TOPIC

A commentary on social justice issues in geriatric surgery FUTURE DIRECTIONS: Recognizing social determinants of health and racism as a contributing mechanism for inequities in the care of older adult surgical patients KNOWLEDGE GAPS: Identifying the role of the surgeon in achieving health equity for older adults PURPOSE: Increase recognition of opportunities for antiracist care in everyday surgical practice, including shared decision-making and palliative care STATE OF THE ART: Patient treatment goals documented in their own words. Social needs screening in older adult surgical patients TECHNOLOGY GAPS: Platform for clear documentation of surgical treatments offered and patient treatment goals, social determinants of health and social risk factors, and collaborative treatment and discharge plans discussed across multidisciplinary, elder-friendly teams.

Association Between Patient-Reported Frailty and Non-Home Discharge Among Older Adults Undergoing Surgery

BACKGROUND/OBJECTIVES

Identifying surgical patients at risk for discharge to a post-acute facility has the potential to reduce hospital length of stay, improve postoperative planning, and increase patient satisfaction. We sought to examine the association between a positive response to a preoperative patient-reported frailty screen and non-home discharge (NHD).

DESIGN

Prospective cohort.

SETTING

Urban tertiary academic preoperative evaluation center.

PARTICIPANTS

Convenience sample of patients aged 60 and older evaluated from November 2018 to August 2019) undergoing one of 14 major elective general and vascular operations with an expected length of stay of 3 days or longer.

METHODS

Items from the previously validated Fatigue, Resistance, Ambulation, Illnesses, Loss of weight (FRAIL) screen were modified, and patients were queried on fatigue, activity against resistance, ambulation, and weight loss. Multivariable logistic regression adjusting for age and sex was used to determine the association between patient-reported items and NHD.

RESULTS

A total of 230 patients were included for analysis. The average age of the cohort was 70.1 (standard deviation = 7.1); 91.7% were White, and 52.4% were female. There were 24 patients (10.4%) who were not discharged home. They were more likely to report fatigue (54% vs 29%; P = .01), weight loss (58% vs 21%; P < .01), and difficulty with activity against resistance (33% vs 7%; P < .01) before surgery. In adjusted analysis, patients who self-reported frailty (FRAIL screen ≥2) were significantly more likely to have an NHD (odds ratio [OR] = 4.5; 95% confidence interval [CI] = 1.7-11.7; P < .01), as were patients who responded "yes" to any question from the FRAIL screen (OR = 2.5; 95% CI = 1.7-3.5; P < .01). A positive response to difficulty with activity against resistance or recent weight loss showed similar odds of NHD (OR = 7.6; 95% CI = 2.6-23.9; P < .01; and OR = 7.9; 95% CI = 2.9-21.6; P < .01, respectively).

CONCLUSION

Patient response to screening questions on the FRAIL screen identified those at highest risk of NHD. The FRAIL screening tool is practical, easy to apply, and could be used during preoperative counseling to identify patients likely to have increased discharge planning needs.

Student Reflections on Interprofessional Education: Moving from Concepts to Collaboration

PURPOSE

We analyzed student reflection essays to evaluate the impact of an interprofessional education (IPE) curriculum on what students value and personally learn from their participation.

METHODS

After completing a 2-year IPE curriculum in the Health Mentors Program (HMP), while partnered with a mentor with chronic disease(s), 264 students from six health professions submitted personal reflection papers, using the Rolfe Reflection-in-Action model. A sample of 60 essays was analyzed using conventional content analysis guided by grounded theory.

RESULTS

Qualitative analysis revealed 15 themes and 14 subthemes in the essays. The themes and subthemes were organized into four main categories: program, mentor, team, and self. Most students viewed the HMP curricular design positively. In particular, they cited the team-based home visit as a critical piece in changing their perceptions of the impact of chronic disease on their health mentor. Mentors' positive attitude and approach toward life also had a profound impact on students. Approximately half of the students identified positive team dynamics as a key component for optimal patient care and better health outcomes, noting improved understanding of team members' professional roles and responsibilities after working together in this longitudinal IPE program. The "self" category had the highest frequency count, with students describing positive changes in self-assessed knowledge, skills, and attitudes.

CONCLUSIONS

Our findings suggest that reflective writing is an effective exercise through which students can explore their attitudes toward IPE and team-based care of individuals with chronic diseases. After participation in this IPE curriculum, students identified having an improved understanding of collaborative practice goals, indicative of meeting an IPE core competency, and described a new understanding of patient-centeredness.