Validity and reliability International Classification of Diseases-10 codes for all forms of injury: A systematic review

BACKGROUND

Intentional and unintentional injuries are a leading cause of death and disability globally. International Classification of Diseases (ICD), Tenth Revision (ICD-10) codes are used to classify injuries in administrative health data and are widely used for health care planning and delivery, research, and policy. However, a systematic review of their overall validity and reliability has not yet been done.

OBJECTIVE

To conduct a systematic review of the validity and reliability of external cause injury ICD-10 codes.

METHODS

MEDLINE, EMBASE, COCHRANE, and SCOPUS were searched (inception to April 2023) for validity and/or reliability studies of ICD-10 external cause injury codes in all countries for all ages. We examined all available data for external cause injuries and injuries related to specific body regions. Validity was defined by sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). Reliability was defined by inter-rater reliability (IRR), measured by Krippendorff's alpha, Cohen's Kappa, and/or Fleiss' kappa.

RESULTS

Twenty-seven published studies from 2006 to 2023 were included. Across all injuries, the mean outcome values and ranges were sensitivity: 61.6% (35.5%-96.0%), specificity: 91.6% (85.8%-100%), PPV: 74.9% (58.6%-96.5%), NPV: 80.2% (44.6%-94.4%), Cohen's kappa: 0.672 (0.480-0.928), Krippendorff's alpha: 0.453, and Fleiss' kappa: 0.630. Poisoning and hand and wrist injuries had higher mean sensitivity (84.4% and 96.0%, respectively), while self-harm and spinal cord injuries were lower (35.5% and 36.4%, respectively). Transport and pedestrian injuries and hand and wrist injuries had high PPVs (96.5% and 92.0%, respectively). Specificity and NPV were generally high, except for abuse (NPV 44.6%).

CONCLUSIONS AND SIGNIFICANCE

The validity and reliability of ICD-10 external cause injury codes vary based on the injury types coded and the outcomes examined, and overall, they only perform moderately well. Future work, potentially utilizing artificial intelligence, may improve the validity and reliability of ICD codes used to document injuries.

Assessment of International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) Code Assignment Validity for Case Finding of Medication-related Hypoglycemia Acute Care Visits Among Medicare Beneficiaries

OBJECTIVE

Administrative claims are commonly relied upon to identify hypoglycemia. We assessed validity of 14 International Classification of Diseases, Tenth Revision, Clinical Modification diagnosis code assignments to identify medication-related hypoglycemia leading to acute care encounters.

RESEARCH DESIGN AND METHODS

A multisite, retrospective medical record review study was conducted in a sample of Medicare beneficiaries prescribed outpatient diabetes medications and who received hospital care between January 1, 2016 and September 30, 2017. Diagnosis codes were validated with structured medical record review using prespecified criteria (clinical presentation, blood glucose values, and treatments for hypoglycemia). Sensitivity, specificity, and positive and negative predictive value (PPV, NPV) were calculated and adjusted using sampling weights to correct for partial verification bias.

RESULTS

Among 990 encounters (496 cases, 494 controls), hypoglycemia codes demonstrated moderate PPV (69.2%; 95% confidence interval: 65.0-73.0) and moderate sensitivity (83.9%; 95% confidence interval: 70.0-95.5). Codes performed better at identifying hypoglycemic events among emergency department/observation encounters compared with hospitalizations (PPV 92.9%, sensitivity 100.0% vs. PPV 53.7%, sensitivity 71.0%). Accuracy varied by diagnosis position, especially for hospitalizations, with PPV of 95.6% versus 46.5% with hypoglycemia in primary versus secondary positions. Use of adverse event/poisoning codes did not improve accuracy; reliance on these codes alone would have missed 97% of true hypoglycemic events.

CONCLUSIONS

Accuracy of International Classification of Diseases, Tenth Revision codes in administrative claims to identify medication-related hypoglycemia varied substantially by encounter type and diagnosis position. Consideration should be given to the trade-off between PPV and sensitivity when selecting codes, encounter types, and diagnosis positions to identify hypoglycemia.

Diagnostic accuracy of ICD code versus discharge summary-based query for endocarditis cohort identification

Studies of infective endocarditis (IE) have relied on International Classification of Disease (ICD) codes to identify cases, a method vulnerable to misclassification. Clinical narrative data could offer greater accuracy and richness to cohort identification. We evaluated two algorithms: 1. a standard query of ICD-9/10 billing codes, with or without procedure codes for echocardiogram and 2. a text query of discharge summaries (DS) that selected on the term “endocarditis” in fields headed by “Discharge Diagnosis” or “Admission Diagnosis” or similar. Further coding extracted valve involved and organism responsible if present. All cases were chart reviewed using pre-specified criteria. Positive predictive value (PPV), sensitivity and specificity were calculated. The ICD-based query identified 612 individuals from July 2015 to July 2019 who had a hospital billing code for infective endocarditis; of these, 534 had an echocardiogram. The DS query identified 387 cases. PPV for the DS query was 84.5% (95% CI 80.6%, 87.8%) compared with 72.4% (95% CI 68.7%, 75.8%) for ICD only (P < .001) and 75.8% (95% CI 72.0%, 79.3%) for ICD + echo queries (P = .002). Sensitivity was 75.9% for DS query and 86.8% to 93.4% for ICD queries (P < .02 for these comparisons). Specificity was high for all queries >94%. The DS query also yielded valve data (prosthetic, tricuspid, aortic, etc) in 60% and microbiologic agent in 73% of identified cases with an accuracy of 94% and 90%, respectively when assessed by chart review. Compared with ICD-based queries, text-based queries of discharge summaries have the potential to improve precision of IE case ascertainment and extract key clinical variables.

Comparative assessment of manual chart review and ICD claims data in evaluating immunotherapy-related adverse events

BACKGROUND

The aim of this retrospective study was to demonstrate that irAEs, specifically gastrointestinal and pulmonary, examined through International Classification of Disease (ICD) data leads to underrepresentation of true irAEs and overrepresentation of false irAEs, thereby concluding that ICD claims data are a poor approach to electronic health record (EHR) data mining for irAEs in immunotherapy clinical research.

METHODS

This retrospective analysis was conducted in 1,063 cancer patients who received ICIs between 2011 and 2017. We identified irAEs by manual review of medical records to determine the incidence of each of our endpoints, namely colitis, hepatitis, pneumonitis, other irAE, or no irAE. We then performed a secondary analysis utilizing ICD claims data alone using a broad range of symptom and disease-specific ICD codes representative of irAEs.

RESULTS

16% (n = 174/1,063) of the total study population was initially found to have either pneumonitis 3% (n = 37), colitis 7% (n = 81) or hepatitis 5% (n = 56) on manual review. Of these patients, 46% (n = 80/174) did not have ICD code evidence in the EHR reflecting their irAE. Of the total patients not found to have any irAEs during manual review, 61% (n = 459/748) of patients had ICD codes suggestive of possible irAE, yet were not identified as having an irAE during manual review.

DISCUSSION

Examining gastrointestinal and pulmonary irAEs through the International Classification of Disease (ICD) data leads to underrepresentation of true irAEs and overrepresentation of false irAEs.

IC-Behavior: An interdisciplinary taxonomy of behaviors

Academic disciplines are often organized according to the behaviors they examine. While most research on a behavior tends to exist within one discipline, some behaviors are examined by multiple disciplines. Better understanding of behaviors and their relationships should enable knowledge transfer across disciplines and theories, thereby dramatically improving the behavioral knowledge base. We propose a taxonomy built on the World Health Organization's International Classification of Functioning, Disability, and Health (ICF), but design the taxonomy as a stand-alone extension rather than an improvement to ICF. Behaviors considered important enough to serve as the dependent variable in articles accepted for publication in top journals were extracted from nine different behavioral and social disciplines. A six-step development and validation process was employed, leading to the final taxonomy. A hierarchy of behaviors under the top banner of Engaging in activities/participating, reflective of ICF's D. hierarchy was constructed with eight immediate domains addressing behaviors ranging from learning, exercising, self-care, and substance use. The resulting International Classification of Behaviors (IC-Behavior), provides a behavior taxonomy targeted towards the interdisciplinary integration of nomological networks relevant to behavioral theories. While IC-Behavior has been labeled v.1.0 to communicate that it is by no means an endpoint, it has empirically shown to provide flexibility for the addition of new behaviors and is tested in the health domain.

Identifying Medicare beneficiaries with dementia

BACKGROUND/OBJECTIVES

No data exist regarding the validity of International Classification of Disease (ICD)-10 dementia diagnoses against a clinician-adjudicated reference standard within Medicare claims data. We examined the accuracy of claims-based diagnoses with respect to expert clinician adjudication using a novel database with individual-level linkages between electronic health record (EHR) and claims.

DESIGN

In this retrospective observational study, two neurologists and two psychiatrists performed a standardized review of patients' medical records from January 2016 to December 2018 and adjudicated dementia status. We measured the accuracy of three claims-based definitions of dementia against the reference standard.

SETTING

Mass-General-Brigham Healthcare (MGB), Massachusetts, USA.

PARTICIPANTS

From an eligible population of 40,690 fee-for-service (FFS) Medicare beneficiaries, aged 65 years and older, within the MGB Accountable Care Organization (ACO), we generated a random sample of 1002 patients, stratified by the pretest likelihood of dementia using administrative surrogates.

INTERVENTION

None.

MEASUREMENTS

We evaluated the accuracy (area under receiver operating curve [AUROC]) and calibration (calibration-in-the-large [CITL] and calibration slope) of three ICD-10 claims-based definitions of dementia against clinician-adjudicated standards. We applied inverse probability weighting to reconstruct the eligible population and reported the mean and 95% confidence interval (95% CI) for all performance characteristics, using 10-fold cross-validation (CV).

RESULTS

Beneficiaries had an average age of 75.3 years and were predominately female (59%) and non-Hispanic whites (93%). The adjudicated prevalence of dementia in the eligible population was 7%. The best-performing definition demonstrated excellent accuracy (CV-AUC 0.94; 95% CI 0.92-0.96) and was well-calibrated to the reference standard of clinician-adjudicated dementia (CV-CITL <0.001, CV-slope 0.97).

CONCLUSION

This study is the first to validate ICD-10 diagnostic codes against a robust and replicable approach to dementia ascertainment, using a real-world clinical reference standard. The best performing definition includes diagnostic codes with strong face validity and outperforms an updated version of a previously validated ICD-9 definition of dementia.

Accuracy of the Geriatric Depression Scale (GDS)-4 and GDS-5 for the screening of depression among older adults: A systematic review and meta-analysis

BACKGROUND

The Geriatric Depression Scale (GDS) is a widely used instrument to assess depression in older adults. The short GDS versions that have four (GDS-4) and five items (GDS-5) represent alternatives for depression screening in limited-resource settings. However, their accuracy remains uncertain.

OBJECTIVE

To assess the accuracy of the GDS-4 and GDS-5 versions for depression screening in older adults.

METHODS

Until May 2020, we systematically searched PubMed, PsycINFO, Scopus, and Google Scholar; for studies that have assessed the sensitivity and specificity of GDS-4 and GDS-5 for depression screening in older adults. We conducted meta-analyses of the sensitivity and specificity of those studies that used the Diagnostic and Statistical Manual of Mental Disorders (DSM) or the International Classification of Diseases-10 (ICD-10) as reference standard. Study quality was assessed with the QUADAS-2 tool. We performed bivariate random-effects meta-analyses to calculate the pooled sensitivity and specificity with their 95% confidence intervals (95% CI) at each reported common cut-off. For the overall meta-analyses, we evaluated each GDS-4 version or GDS-5 version separately by each cut-off, and for investigations of heterogeneity, we assessed altogether across similar GDS versions by each cut-off. Also, we assessed the certainty of evidence using the GRADE methodology.

RESULTS

Twenty-three studies were included and meta-analyzed, assessing eleven different GDS versions. The number of participants included was 5048. When including all versions together, at a cut-off 2, GDS-4 had a pooled sensitivity of 0.77 (95% CI: 0.70-0.82) and a pooled specificity of 0.75 (0.68-0.81); while GDS-5 had a pooled sensitivity of 0.85 (0.80-0.90) and a pooled specificity of 0.75 (0.69-0.81). We found results for more than one GDS-4 version at cut-off points 1, 2, and 3; and for more than one GDS-5 version at cut-off points 1, 2, 3, and 4. Mostly, significant subgroup differences at different test thresholds across versions were found. The accuracy of the different GDS-4 and GDS-5 versions showed a high heterogeneity. There was high risk of bias in the index test domain. Also, the certainty of the evidence was low or very low for most of the GDS versions.

CONCLUSIONS

We found several GDS-4 and GDS-5 versions that showed great heterogeneity in estimates of sensitivity and specificity, mostly with a low or very low certainty of the evidence. Altogether, our results indicate the need for more well-designed studies that compare different GDS versions.

Evaluating the association between American Association for the Surgery of Trauma emergency general surgery anatomic severity grades and clinical outcomes using national claims data

BACKGROUND

Emergency general surgery (EGS) encompasses a heterogeneous population of acutely ill patients, and standardized methods for determining disease severity are essential for comparative effectiveness research and quality improvement initiatives. The American Association for the Surgery of Trauma (AAST) has developed a grading system for the anatomic severity of 16 EGS conditions; however, little is known regarding how well these AAST EGS grades can be approximated by diagnosis codes in administrative databases.

METHODS

We identified adults admitted for 16 common EGS conditions in the 2012 to 2017q3 National Inpatient Sample. Disease severity strata were assigned using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) and International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) diagnosis codes based on AAST EGS anatomic severity grades. We evaluated whether assigned EGS severity (multiple strata or dichotomized into less versus more complex) were associated with in-hospital mortality, complications, length of stay, discharge disposition, and costs. Analyses were adjusted for age, sex, comorbidities, hospital traits, geography, and year.

RESULTS

We identified 10,886,822 EGS admissions. The number of anatomic severity strata derived from ICD-9/10-CM codes varied by EGS condition and by year. Four conditions mapped to four strata across all years. Two conditions mapped to four strata with ICD-9-CM codes but only two or three strata with ICD-10-CM codes. Others mapped to three or fewer strata. When dichotomized into less versus more complex disease, patients with more complex disease had worse outcomes across all 16 conditions. The addition of multiple strata beyond a binary measure of complex disease, however, showed inconsistent results.

CONCLUSION

Classification of common EGS conditions according to anatomic severity is feasible with International Classification of Diseases codes. No condition mapped to five distinct severity grades, and the relationship between increasing grade and outcomes was not consistent across conditions. However, a standardized measure of severity, even if just dichotomized into less versus more complex, can inform ongoing efforts aimed at optimizing outcomes for EGS patients across the nation.

LEVEL OF EVIDENCE

Prognostic, level III.

The Challenges of Using ICD codes to Perform a Comparative Analysis between Patients with Penetrating Cardiac Injuries who Underwent Non-Resuscitative Thoracotomy versus Sternotomy

BACKGROUND

Comparative morbidity after either sternotomy or non-resuscitative thoracotomy in penetrating cardiac injuries (PCI) is unknown.

METHODS

Retrospective review of adults with PCI who underwent either sternotomy or non-resuscitative thoracotomy using the National Trauma Data Bank 2007-2015. Since there is no unique International Classification of Diseases Procedure Coding System (ICD-PCS) codes assigned for resuscitative vs. non-resuscitative thoracotomy, and both procedures were coded as "thoracotomy", propensity score (PS) methods were applied to avoid inclusion of resuscitative thoracotomy.

RESULTS

Despite well PS matching on injury severity score the non-thoracotomy group compared to the sternotomy group had a significantly increased risk of mortality (30 percent vs 8 percent, p<0.0001). The morbidity differed as well-25 percent vs. 12 percent, p=0.0007.

CONCLUSIONS

The differences in mortality in PCI patients who underwent non-resuscitative thoracotomy vs. sternotomy may be biased by unintentional inclusion of resuscitative thoracotomy. To accurately capture thoracotomy type, separate unique resuscitative and non-resuscitative thoracotomy procedure codes should be created in future revisions of the ICD PCS.

Development and Testing of Compatible Diagnosis Code Lists for the Functional Comorbidity Index: International Classification of Diseases, Ninth Revision, Clinical Modification and International Classification of Diseases, 10th Revision, Clinical Modification

BACKGROUND

The Functional Comorbidity Index (FCI) was developed for community-based adult populations, with function as the outcome. The original FCI was a survey tool, but several International Classification of Diseases (ICD) code lists-for calculating the FCI using administrative data-have been published. However, compatible International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) and ICD-10-CM versions have not been available.

OBJECTIVE

We developed ICD-9-CM and ICD-10-CM diagnosis code lists to optimize FCI concordance across ICD lexicons.

RESEARCH DESIGN

We assessed concordance and frequency distributions across ICD lexicons for the FCI and individual comorbidities. We used length of stay and discharge disposition to assess continuity of FCI criterion validity across lexicons.

SUBJECTS

State Inpatient Databases from Arizona, Colorado, Michigan, New Jersey, New York, Utah, and Washington State (calendar year 2015) were obtained from the Healthcare Cost and Utilization Project. State Inpatient Databases contained ICD-9-CM diagnoses for the first 3 calendar quarters of 2015 and ICD-10-CM diagnoses for the fourth quarter of 2015. Inpatients under 18 years old were excluded.

MEASURES

Length of stay and discharge disposition outcomes were assessed in separate regression models. Covariates included age, sex, state, ICD lexicon, and FCI/lexicon interaction.

RESULTS

The FCI demonstrated stability across lexicons, despite small discrepancies in prevalence for individual comorbidities. Under ICD-9-CM, each additional comorbidity was associated with an 8.9% increase in mean length of stay and an 18.5% decrease in the odds of a routine discharge, compared with an 8.4% increase and 17.4% decrease, respectively, under ICD-10-CM.

CONCLUSION

This study provides compatible ICD-9-CM and ICD-10-CM diagnosis code lists for the FCI.

Differential-diagnostic confusion and non-specificity of affective symptoms and anxiety: An empirical study of first-admission patients

In everyday clinical work, psychiatrists encounter patients who present with symptoms spanning several diagnostic categories, e.g., showing signs of a psychosis, depression, and anxiety. This raises the critical question of which symptoms hold precedence over other and, by extension, which diagnosis is the right diagnosis. ICD-10 and DSM-5 do not provide unambiguous answers to this question and therefore psychiatry remains exposed to diagnostic disagreement with consequences for treatment and research. We explored symptom distribution in a sample of 98 first-admission psychiatric patients. We extracted and categorized singular symptoms into symptom domains: anxiety, mania, delusions, hallucinations, first-rank symptoms, and negative symptoms. Most symptoms were seen in most disorders. We found symptoms of depression and anxiety in almost all patients. Thus, just counting symptoms do not seem to be a valid way to make diagnoses. We elaborately discuss these issues in the context of the differential-diagnosis between schizophrenia and depression. Finally, we suggest that a combination of a criteria- and Gestalt-based approach to diagnosing mental disorders may contribute to counteract some of the current differential-diagnostic confusion.

Linking the effect of psoriatic arthritis-related foot involvement to the Leeds Foot Impact Scale using the International Classification for Functioning, Disability and Health: a study to assess content validity

BACKGROUND

Previous research to describe the impact of foot involvement in psoriatic arthritis has used the Leeds Foot Impact Scale in Rheumatoid Arthritis (LFIS-RA) in the current absence of any psoriatic arthritis foot-specific tools. However, the LFIS-RA is a rheumatoid arthritis disease-specific outcome measure and its content validity for evaluating the experiences of people with psoriatic arthritis-related foot involvement is unknown. The study objective was to determine the content validity of the LFIS-RA for assessing people with psoriatic arthritis, using the International Classification of Functioning, Disability and Health (ICF) as the frame of reference.

METHOD

Concepts within each item of the LFIS-RA were linked to the best-matched ICF categories using established linking rules, which enable a systematic and standardised linking process. All concepts were independently linked to the ICF by 2 investigators with different professional backgrounds, which included occupational therapy and podiatry. The list of ICF categories derived from previous research that pertained to the foot in psoriatic arthritis was then compared with the ICF categories linked to the LFIS-RA. The comparison was undertaken in order to determine the extent to which concepts important and relevant to people with psoriatic arthritis-related foot involvement were addressed.

RESULTS

Thirty-five distinct ICF categories were linked to the LFIS-RA, which related to body functions (44%), activities and participation (35%), environmental factors (16%) and body structure (5%). In comparison with the ICF categories derived from concepts of the foot in psoriatic arthritis previously defined, the LFIS-RA provided coverage of key constructs including pain, functioning, daily activities, footwear restrictions and psychological impact. Other concepts of importance in psoriatic arthritis such as skin and toenail involvement, self-management and paid employment were not addressed in the LFIS-RA.

CONCLUSION

Content validity of the LFIS-RA to determine the impact of foot functional impairments and disability in people with psoriatic arthritis was not supported by the results of this study. Future work should consider the development of a psoriatic arthritis foot-specific patient reported outcome measure, using the LFIS-RA as an important foundation.

Accuracy of ICD-9 codes in identifying patients with peptic ulcer and gastrointestinal hemorrhage in the regional healthcare administrative database of Umbria

Background

Peptic ulcer is a widespread disease, frequently complicated by perforation and bleeding. Administrative databases are useful tool to perform epidemiological and drug utilization studies, but they need a validation process based on a comparison with the original data contained in the medical charts. Our aim was to evaluate the accuracy of the ICD-9 codes in identifying patients with peptic ulcer and gastrointestinal hemorrhage in the regional administrative database of Umbria.

Methods

The index test of our study was the hospital discharge abstract database of the Umbria region (Italy), while the reference standard was the clinical information collected in the medical charts. The study population were adult patients with a hospital discharge for peptic ulcer or gastrointestinal hemorrhage in the period 2012–2014. A random sample of cases and non-cases was selected and the corresponding medical charts were reviewed. Cases of peptic ulcer were confirmed based on endoscopy, radiology, and surgery, while adjudication of gastrointestinal hemorrhage was based on presence of hematemesis, melena, and rectal bleeding.

Results

Overall, we reviewed 445 clinical charts of cases and 80 clinical charts of non-cases. The diagnostic accuracy results were: code 531 (gastric ulcer), sensitivity and NPV 98%, specificity 88%, and PPV 91%; code 532 (duodenal ulcer), sensitivity and NPV 100%, specificity and PPV 98%; code 534 (gastrojejunal ulcer), sensitivity and NPV 100%, specificity 70%, and PPV 45%; code 578 (gastrointestinal hemorrhage), sensitivity 96%, specificity 90%, PPV and NPV 94%.

Conclusions

Our results showed a high level of diagnostic accuracy for most of the codes considered. The ICD-9 code 534 of gastrojejunal ulcer had a lower level of specificity and PPV due to false positives, being mainly misclassifications for coding errors. These validated codes can be used for future epidemiological studies and for health services research.

Assessment of the Accuracy of Using ICD-9 Diagnosis Codes to Identify Pneumonia Etiology in Patients Hospitalized With Pneumonia

IMPORTANCE

Administrative databases may offer efficient clinical data collection for studying epidemiology, outcomes, and temporal trends in health care delivery. However, such data have seldom been validated against microbiological laboratory results.

OBJECTIVE

To assess the validity of International Classification of Diseases, Ninth Revision (ICD-9) organism-specific administrative codes for pneumonia using microbiological data (test results for blood or respiratory culture, urinary antigen, or polymerase chain reaction) as the criterion standard.

DESIGN, SETTING, AND PARTICIPANTS

Cross-sectional diagnostic accuracy study conducted between February 2017 and June 2019 using data from 178 US hospitals in the Premier Healthcare Database. Patients were aged 18 years or older admitted with pneumonia and discharged between July 1, 2010, and June 30, 2015. Data were analyzed from February 14, 2017, to June 27, 2019.

EXPOSURES

Organism-specific pneumonia identified from ICD-9 codes.

MAIN OUTCOMES AND MEASURES

Sensitivity, specificity, positive predictive value, and negative predictive value of ICD-9 codes using microbiological data as the criterion standard.

RESULTS

Of 161 529 patients meeting inclusion criteria (mean [SD] age, 69.5 [16.2] years; 51.2% women), 35 759 (22.1%) had an identified pathogen. ICD-9-coded organisms and laboratory findings differed notably: for example, ICD-9 codes identified only 14.2% and 17.3% of patients with laboratory-detected methicillin-sensitive Staphylococcus aureus and Escherichia coli, respectively. Although specificities and negative predictive values exceeded 95% for all codes, sensitivities ranged downward from 95.9% (95% CI, 95.3%-96.5%) for influenza virus to 14.0% (95% CI, 8.8%-20.8%) for parainfluenza virus, and positive predictive values ranged downward from 91.1% (95% CI, 89.5%-92.6%) for Staphylococcus aureus to 57.1% (95% CI, 39.4%-73.7%) for parainfluenza virus.

CONCLUSIONS AND RELEVANCE

In this study, ICD-9 codes did not reliably capture pneumonia etiology identified by laboratory testing; because of the high specificities of ICD-9 codes, however, administrative data may be useful in identifying risk factors for resistant organisms. The low sensitivities of the diagnosis codes may limit the validity of organism-specific pneumonia prevalence estimates derived from administrative data.

Drowning: epidemiology, prevention, pathophysiology, resuscitation, and hospital treatment

This narrative review discusses the evidence relevant to key aspects of drowning, which is defined by the World Health Organization as the process of respiratory difficulty caused by submersion/immersion in liquid. The length of time the victim is submerged is a key factor in survival and neurologic damage. Although respiratory distress and hypoxia are the main events, other complications affecting various systems and organs may develop. Drowning is one of the main causes of accidental death worldwide, yet deaths from drowning are underestimated and morbidity is unknown. Prevention is essential for reducing both mortality and morbidity, but if prevention fails, the speed of access to and the quality of prehospital and hospital care will determine the prognosis. It is therefore essential to understand the factors and mechanisms involved in these emergencies.

Treatment of retinopathy of prematurity (ROP) outside International Classification of ROP (ICROP) guidelines

AIM

To evaluate the incidence and clinical indications for which eyes were treated for retinopathy of prematurity (ROP) outside the guidelines set by International Classification of ROP (ICROP).

METHODS

Medical records of the patients treated at a single tertiary care ophthalmology hospital for ROP from January 2016 to December 2019 were retrospectively analysed to evaluate the indications for which they were treated.

RESULTS

Out of 241 eyes, 33 eyes (13.7%) were treated outside the guidelines. The reasons for the treatment outside the guidelines were structural changes (n = 24, 72.7%), persistent stage 3 ROP that did not show any sign of regression for 6 weeks (n = 7, 21.2%) and active ROP with fellow eye being treated (n = 2, 6.1%). The recorded specific structural changes were tangential traction with temporal vessel straightening concerning for macular distortion and ectopia (n = 5, 15.2%), and stage 3 neovascularisation or ridge with anteroposterior traction with risk of progression to stage 4 disease (n = 19, 57.6%). Pre-plus disease was present in 11 eyes (33.3%).After the treatment, ROP stages regressed and retinal vessels grew either until the ora or at least into zone III in all the treated eyes. None of the eyes showed worsening of structural changes after treatment. The mean follow-up of the patients was 12.4 ± 11.7 months.

CONCLUSION

Experts occasionally recommend treatment in eyes with disease milder than type 1 ROP. This study may help paediatric retinal practitioners in decision-making in borderline cases.

The necessity of developing a two-stage qualification in ICD-11

In the International Classification of Diseases, 10th Revision (ICD-10) two opposing principles are combined and mixed: atheoreticity that is necessary for the natural classification and commitment to nosology. Implementation of these principles requires a two-stage qualification. The first stage should be narrative detailed syndromological qualifications with identification of psychotic level of disorders. As for the second stage, the qualification should be nosological, based on complete clinical analysis, which is far from being possible to realize at once. ICD-10, specifically brought to nosological certainty, may remain the natural foundation for nosological qualification. Implementation of the syndromic qualification at the first stage will allow to consider nosological features of each syndrome at the second stage and to expand the list of criteria in different clusters. Such a suggestion opens the prospect for subsequent revisions of the ICD and allows to direct our efforts and those of practitioners to the unified channel, where the statistical goals would not be implemented at the expense of the research ones.

The association between Bell's palsy and rheumatoid arthritis: A longitudinal study

This study aimed to evaluate the relationship between Bell's palsy and rheumatoid arthritis in a national sample cohort from Korea.Data were collected for individuals ≥20 years old from 2002 to 2013 in the Korean National Health Insurance Service-National Sample Cohort. We extracted data for patients with rheumatoid arthritis (n = 7628) and 1:4-matched controls (n = 30,512) and analyzed the occurrence of Bell's palsy in both groups. Matching was performed based on age, sex, income, and region of residence. Rheumatoid arthritis was diagnosed according to International Classification of Disease-10 (ICD-10) codes (M05-M06) and the prescription of biological agents and/or disease-modifying antirheumatic drugs. Bell's palsy patients were diagnosed according to ICD-10 code H912 and treatment ≥2 times with steroids. Adjusted hazard ratios (HRs) were calculated using stratified Cox proportional hazard models for the Charlson comorbidity index and 95% confidence intervals (CIs). Subgroup analyses based on age and sex were also performed.The rates of Bell's palsy were similar between the rheumatoid arthritis group (0.5% [38/7628]) and the control group, with no significant difference (0.4% [124/30,512], P = .270). The adjusted HR for Bell's palsy was 1.12 (95% CI, 0.78-1.62) in the rheumatoid arthritis group (P = .540). In the subgroup analyses according to age and sex, the relationship between Bell's palsy and rheumatoid arthritis did not reach statistical significance.The risk of Bell's palsy was not increased in patients with rheumatoid arthritis.

Mental, behavioral and neurodevelopmental disorders in the ICD-11: an international perspective on key changes and controversies

An update of the chapter on Mental, Behavioral and Neurodevelopmental Disorders in the International Classification of Diseases and Related Health Problems (ICD) is of great interest around the world. The recent approval of the 11th Revision of the ICD (ICD-11) by the World Health Organization (WHO) raises broad questions about the status of nosology of mental disorders as a whole as well as more focused questions regarding changes to the diagnostic guidelines for specific conditions and the implications of these changes for practice and research. This Forum brings together a broad range of experts to reflect on key changes and controversies in the ICD-11 classification of mental disorders. Taken together, there is consensus that the WHO's focus on global applicability and clinical utility in developing the diagnostic guidelines for this chapter will maximize the likelihood that it will be adopted by mental health professionals and administrators. This focus is also expected to enhance the application of the guidelines in non-specialist settings and their usefulness for scaling up evidence-based interventions. The new mental disorders classification in ICD-11 and its accompanying diagnostic guidelines therefore represent an important, albeit iterative, advance for the field.

Electronic Health Record Phenotypes for Identifying Patients with Late-Stage Disease: a Method for Research and Clinical Application

BACKGROUND

Systematic identification of patients allows researchers and clinicians to test new models of care delivery. EHR phenotypes-structured algorithms based on clinical indicators from EHRs-can aid in such identification.

OBJECTIVE

To develop EHR phenotypes to identify decedents with stage 4 solid-tumor cancer or stage 4-5 chronic kidney disease (CKD).

DESIGN

We developed two EHR phenotypes. Each phenotype included International Classification of Diseases (ICD)-9 and ICD-10 codes. We used natural language processing (NLP) to further specify stage 4 cancer, and lab values for CKD.

SUBJECTS

Decedents with cancer or CKD who had been admitted to an academic medical center in the last 6 months of life and died August 26, 2017-December 31, 2017.

MAIN MEASURE

We calculated positive predictive values (PPV), false discovery rates (FDR), false negative rates (FNR), and sensitivity. Phenotypes were validated by a comparison with manual chart review. We also compared the EHR phenotype results to those admitted to the oncology and nephrology inpatient services.

KEY RESULTS

The EHR phenotypes identified 271 decedents with cancer, of whom 186 had stage 4 disease; of 192 decedents with CKD, 89 had stage 4-5 disease. The EHR phenotype for stage 4 cancer had a PPV of 68.6%, FDR of 31.4%, FNR of 0.5%, and 99.5% sensitivity. The EHR phenotype for stage 4-5 CKD had a PPV of 46.4%, FDR of 53.7%, FNR of 0.0%, and 100% sensitivity.

CONCLUSIONS

EHR phenotypes efficiently identified patients who died with late-stage cancer or CKD. Future EHR phenotypes can prioritize specificity over sensitivity, and incorporate stratification of high- and low-palliative care need. EHR phenotypes are a promising method for identifying patients for research and clinical purposes, including equitable distribution of specialty palliative care.

IMP-ICDX: an injury mortality prediction based on ICD-10-CM codes

Background

The International Classification of Diseases, Ninth Edition, Clinical Modification (ICD-9-CM) Injury Severity Score (ICISS) is a risk adjustment model when injuries are recorded using ICD-9-CM coding. The trauma mortality prediction model (TMPM-ICD9) provides better calibration and discrimination compared with ICISS and injury severity score (ISS). Though TMPM-ICD9 is statistically rigorous, it is not precise enough mathematically and has the tendency to overestimate injury severity. The purpose of this study is to develop a new ICD-10-CM injury model which estimates injury severities for every injury in the ICD-10-CM lexicon by a combination of rigorous statistical probit models and mathematical properties and improves the prediction accuracy.

Methods

We developed an injury mortality prediction (IMP-ICDX) using data of 794,098 patients admitted to 738 hospitals in the National Trauma Data Bank from 2015 to 2016. Empiric measures of severity for each of the trauma ICD-10-CM codes were estimated using a weighted median death probability (WMDP) measurement and then used as the basis for IMP-ICDX. ISS (version 2005) and the single worst injury (SWI) model were re-estimated. The performance of each of these models was compared by using the area under the receiver operating characteristic (AUC), the Hosmer-Lemeshow (HL) statistic, and the Akaike information criterion statistic.

Results

IMP-ICDX exhibits significantly better discrimination (AUCIMP-ICDX, 0.893, and 95% confidence interval (CI), 0.887 to 0.898; AUCISS, 0.853, and 95% CI, 0.846 to 0.860; and AUCSWI, 0.886, and 95% CI, 0.881 to 0.892) and calibration (HLIMP-ICDX, 68, and 95% CI, 36 to 98; HLISS, 252, and 95% CI, 191 to 310; and HLSWI, 92, and 95% CI, 53 to 128) compared with ISS and SWI. All models were improved after the extension of age, gender, and injury mechanism, but the augmented IMP-ICDX still dominated ISS and SWI by every performance.

Conclusions

The IMP-ICDX has a better discrimination and calibration compared to ISS. Therefore, we believe that IMP-ICDX could be a new viable trauma research assessment method.

Standardization of State Definitions for Neonatal Abstinence Syndrome Surveillance and the Opioid Crisis

Rates of neonatal abstinence syndrome (NAS) have increased fivefold in the past decade. To address this expanding and complex issue, state public health agencies have addressed the opioid crisis affecting newborns in diverse ways, leading to a variety of methods to quantify the burden of NAS.In an effort to understand this variability, we summarized clinical case and surveillance definitions used across jurisdictions in the United States. We confirmed that the rapid progression of the nation's opioid crisis resulted in heterogeneous processes for identifying NAS. Current clinical case definitions use different combinations of clinician-observed signs of withdrawal and evidence of perinatal substance exposure. Similarly, there is discordance in diagnosis codes used in surveillance definitions. This variability makes it difficult to produce comparable estimates across jurisdictions, which are needed to effectively guide public health strategies and interventions.Although standardization is complicated, consistent NAS definitions would increase comparability of NAS estimates across the nation and would better guide prevention and treatment efforts for women and their infants.

An empirical evaluation of deep learning for ICD-9 code assignment using MIMIC-III clinical notes

BACKGROUND AND OBJECTIVE

Code assignment is of paramount importance in many levels in modern hospitals, from ensuring accurate billing process to creating a valid record of patient care history. However, the coding process is tedious and subjective, and it requires medical coders with extensive training. This study aims to evaluate the performance of deep-learning-based systems to automatically map clinical notes to ICD-9 medical codes.

METHODS

The evaluations of this research are focused on end-to-end learning methods without manually defined rules. Traditional machine learning algorithms, as well as state-of-the-art deep learning methods such as Recurrent Neural Networks and Convolution Neural Networks, were applied to the Medical Information Mart for Intensive Care (MIMIC-III) dataset. An extensive number of experiments was applied to different settings of the tested algorithm.

RESULTS

Findings showed that the deep learning-based methods outperformed other conventional machine learning methods. From our assessment, the best models could predict the top 10 ICD-9 codes with 0.6957 F₁ and 0.8967 accuracy and could estimate the top 10 ICD-9 categories with 0.7233 F₁ and 0.8588 accuracy. Our implementation also outperformed existing work under certain evaluation metrics.

CONCLUSION

A set of standard metrics was utilized in assessing the performance of ICD-9 code assignment on MIMIC-III dataset. All the developed evaluation tools and resources are available online, which can be used as a baseline for further research.

Identifying mental health and substance use disorders using emergency department and hospital records: a population-based retrospective cohort study of diagnostic concordance and disease attribution

OBJECTIVES

Administrative data are increasingly being used for surveillance and monitoring of mental health and substance use disorders (MHSUD) across Canada. However, the validity of the diagnostic codes specific to MHSUD is unknown in emergency departments (EDs). Our objective was to determine the concordance, and individual-level and hospital-level factors associated with concordance, between diagnosis codes assigned in ED and at discharge from hospital for MHSUD-related conditions.

DESIGN

Population-based retrospective cohort study.

SETTING

EDs and hospitals within Vancouver Coastal Health Authority (VCH), British Columbia, Canada.

PARTICIPANTS

16 926 individuals who were admitted into a VCH hospital following an ED visit from 1 April 2009 to 31 March 2017, contributing to 48 116 pairs of ED and hospital discharge diagnoses.

PRIMARY AND SECONDARY OUTCOME MEASURES

We examined concordance in identifying MHSUD between the primary discharge diagnosis codes based on the International Statistical Classification of Diseases, 9th and 10th Revisions (Canada) assigned in the ED and those assigned in the hospital among all ED visits resulting in a hospital admission. We calculated the percent overall agreement, positive agreement, negative agreement and Cohen's kappa coefficient. We performed multiple regression analyses to identify factors independently associated with discordance.

RESULTS

We found a high level of concordance for broad categories of MH conditions (overall agreement=0.89, positive agreement=0.74 and kappa=0.67), and a fair level of concordance for SUDs (overall agreement=0.89, positive agreement=0.31 and kappa=0.27). SUDs were less likely to be indicated as the primary cause in ED as opposed to in hospital (3.8% vs 11.7%). In multiple regression analyses, ED visits occurring during holidays, weekends and overnight (21:00-8:59 hours) were associated with increased odds of discordance in identifying MH conditions (adjusted OR 1.47, 95% CI 1.11 to 1.93; 1.27, 95% CI 1.16 to 1.40; 1.30, 95% CI 1.19 to 1.42, respectively).

CONCLUSIONS

ED data could be used to improve surveillance and monitoring of MHSUD. Future efforts are needed to improve screening for individuals with MHSUD and subsequently connect them to treatment and follow-up care.

An Updated International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) Surveillance Case Definition for Injury Hospitalizations

The National Center for Health Statistics (NCHS) and National Center for Injury Prevention and Control (NCIPC) have routinely collaborated with injury epidemiology partners to develop standard injury surveillance case definitions based on the International Classification of Diseases (ICD). With the transition in October 2015 to the use of the ICD, 10th Revision, Clinical Modification (ICD-10-CM) for reporting medical information in administrative claims data, NCHS and NCIPC proposed an ICD-10-CM surveillance case definition for injury hospitalizations. At the time, ICD-10-CM coded data were not readily available, and the proposed surveillance definition could not be tested using real data. As ICD-10-CM coded data became available, NCHS and NCIPC collaborated with the Council of State and Territorial Epidemiologists, injury epidemiologists from state and local health departments, and the Agency for Healthcare Research and Quality to test the proposed definition. This report summarizes the findings from the testing process and describes how the findings were used to update the proposed case definition. In the updated ICD-10-CM surveillance case definition, injury hospitalizations are identified as hospitalization records with a principal diagnosis of select ICD-10-CM S, T, O, and M codes. The codes must indicate an initial encounter for active treatment of an injury or be missing encounter type information. The selection criteria exclude hospitalization records with an injury as a secondary or subsequent diagnosis (not the principal diagnosis) or that have an external cause-of-injury code but do not have an injury code as the principal diagnosis. The updated ICD-10-CM surveillance case definition for injury hospitalizations provides standardized selection criteria for monitoring differences in hospitalization rates among populations and over time.

Towards controlled terminology for reporting germline cancer susceptibility variants: an ENIGMA report

The vocabulary currently used to describe genetic variants and their consequences reflects many years of studying and discovering monogenic disease with high penetrance. With the recent rapid expansion of genetic testing brought about by wide availability of high-throughput massively parallel sequencing platforms, accurate variant interpretation has become a major issue. The vocabulary used to describe single genetic variants in silico, in vitro, in vivo and as a contributor to human disease uses terms in common, but the meaning is not necessarily shared across all these contexts. In the setting of cancer genetic tests, the added dimension of using data from genetic sequencing of tumour DNA to direct treatment is an additional source of confusion to those who are not experienced in cancer genetics. The language used to describe variants identified in cancer susceptibility genetic testing typically still reflects an outdated paradigm of Mendelian inheritance with dichotomous outcomes. Cancer is a common disease with complex genetic architecture; an improved lexicon is required to better communicate among scientists, clinicians and patients, the risks and implications of genetic variants detected. This review arises from a recognition of, and discussion about, inconsistencies in vocabulary usage by members of the ENIGMA international multidisciplinary consortium focused on variant classification in breast-ovarian cancer susceptibility genes. It sets out the vocabulary commonly used in genetic variant interpretation and reporting, and suggests a framework for a common vocabulary that may facilitate understanding and clarity in clinical reporting of germline genetic tests for cancer susceptibility.

Evaluating the assessment of the ICD-11 personality disorder diagnostic system

Proposed for the ICD-11 is a dimensional model of personality disorder that, if approved, would be a paradigm shift in the conceptualization of personality disorder. The proposal consists of a general severity rating, 5 maladaptive personality trait domains, and a borderline pattern qualifier. The general severity rating can be assessed by the Standardized Assessment of Severity of Personality Disorder (SASPD), the trait domains by the Personality Inventory for ICD-11 (PiCD), and the borderline pattern by the Borderline Pattern Scale (BPS), which is developed in the present study. To date, no study has examined the relations among all 3 components, due in part to the absence of direct measures for each component (until recently). The current study develops and provides initial validation evidence for the BPS, and examines the relations among the BPS, SASPD, and PiCD. Also considered is their relationship with the 5-factor model of general personality as well as with 2 other measures of personality disorder severity (including the DSM-5 Level of Personality Functioning Scale [LPFS]). Further, an alternative trait-based coding of the DSM-5 LPFS is examined (modeled after the ICD-11 SASPD), suggesting that its coverage of diverse maladaptivity may not be because it assesses the core of personality disorder, but rather because it has items specific to the different domains of personality. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Developing behavioural indicators for intellectual functioning and adaptive behaviour for ICD-11 disorders of intellectual development

BACKGROUND

We present the work conducted to arrive at deriving behavioural indicators that could be used to guide clinical judgement in determining the presence and severity of deficits in intellectual functioning and adaptive behaviour for the purpose of making a diagnosis of disorders of intellectual development.

METHODS

An interdisciplinary expert panel provided guidance in developing behavioural indicators for intellectual functioning. A national dataset of adaptive behaviour on a sample of individuals with a diagnosis of intellectual disability was used to develop the behavioural indicators for the adaptive behaviour. The adaptive behaviour data were analysed using a cluster analysis procedure to define the different severity groupings by chronological age groups.

RESULTS

We present a series of tables containing behavioural indicators across the lifespan for intellectual functioning and adaptive behaviour, including conceptual, social and practical skills. These tables of behavioural indicators have been proposed for use in the clinical version of the 11th revision of the International Classification of Diseases and Related Health Problems (ICD-11) to be published by the World Health Organization.

CONCLUSIONS

The proposed behavioural indicators for disorders of ID described in the present article and to be included in the ICD-11 Clinical Descriptions and Diagnostic Guidelines are put forth to assist professionals in making an informed clinical decision regarding an individual's level of intellectual functioning and adaptive behaviour for the purpose of making a determination about the presence and severity of disorders of ID.

Challenges of Using ICD-9-CM and ICD-10-CM Codes for Soft-Tissue Sarcoma in Databases for Health Services Research

OBJECTIVES

Soft-tissue sarcoma (STS) is a heterogeneous group of rare solid tumors that arise from various soft tissues in the body, such as muscle, fat, nerves, and blood vessels. Current International Classification of Diseases (ICD) coding systems include a set of nonspecific codes for malignancies of connective and soft tissue (ICD-9-CM code 171 and ICD-10-CM code C49). The goal of this study was to evaluate the use of these codes for health services research involving patients with a diagnosis of this rare malignancy.

METHODS

Two databases were utilized to explore ICD coding for STS: claims data from Truven MarketScan and electronic medical records (EMRs) from Flatiron Health. Eligible patients from claims data were those with at least two ICD-9-CM codes of 171.x on two different days between July 1, 2004, and March 30, 2014. The treatment patterns of these cases were evaluated for consistency with known therapeutic approaches for STS. Eligible patients from the Flatiron EMR system were those who received olaratumab (a drug indicated only for use in patients diagnosed with STS) after its US Food and Drug Administration approval in October 2016 through the end of the data set (November 2017). ICD-10-CM codes were evaluated for this known STS cohort.

RESULTS

In claims data, 4,159 patients were eligible for inclusion. Although national treatment guidelines include only a limited number of drugs used to treat STS, 98 unique anticancer drugs were identified as being used to treat patients in a claims data cohort. Only 7.7 percent of patients had claims for doxorubicin-based therapy and 3.8 percent had claims for ifosfamide-based therapy as initial treatment for STS, despite these being a standard of care. In the EMR data, 350 patients were eligible; only 170 patients (48.6 percent) had any evidence in the database of a connective or soft-tissue ICD-10-CM malignancy code within 60 days before or after initiation of olaratumab.

CONCLUSIONS

ICD coding for STS using the "Malignant neoplasm of connective and soft tissue" code is not reliable as a method to identify patients diagnosed with STS. Although codes reflecting the primary site of disease may have clinical relevance, lack of consistency in ICD coding for the diagnosis and treatment of this disease is a limiting factor in the ability to conduct real-world observational research of this rare disease. In the absence of consistent use of this code, an algorithm needs to be developed and validated to accurately identify patients with STS in these databases.

Analyzing the ICD-10-CM Transition and Post-implementation Stages: A Public Health Institution Case Study

On October 1, 2015, the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) was incorporated into the US public health system. Because of significant opposition and reservations expressed by stakeholders, while the proposed rule for ICD-10-CM adoption was issued in 2009, the transition did not occur until October 2015. The purpose of this study was to identify conversion initiatives used by a public health institution during the initial and subsequent stages of ICD-10-CM implementation, to help similar institutions address future unfunded healthcare data infrastructure mandates. The data collection for this study occurred from 2015 to 2018, encompassing 20 semistructured interviews with 13 department heads, managers, physicians, and coders. Research findings from this study identified several trends, disruptions, challenges, and lessons learned that might support the industry with strategies to foster success for the transition to future coding revisions (i.e., ICD-11).

[An online dynamic knowledge base in multiple languages on general medicine and primary care]

INTRODUCTION

The International Classification of Primary Care, Second version (ICPC-2) aligned with the 10th Revision of the International Classification of Disease (ICD-10) is a standard for primary care epidemiology compendium. ICPC-2 has been also intended to identify the clinical topics in family medicine. Contextual field-specific knowledge in family medicine and primary care such as health structures, management, categories of patients, research methods, ethical or environmental features are not standardized and reflect, more often, the views of experts.

METHODS

A qualitative research method, applied to the analysis of several Family Medicine congresses, has helped identify, in addition to clinical items, a spectrum of contextual concepts addressed by family doctors during their exchanges at the congresses. Assembled in a hierarchical manner, these concepts were given expression, together with ICPC-2, under the name of Q-codes Version 2.5, in the multilingual multi-terminology semantic server of the Department of Information and medical informatics (D2Im) at the University of Rouen, France. The two classifications are edited under the acronym 3 CGP for Core Content classification of General Practice. This free access server allows you to consult the ICPC-2 in 22 languages and the Q-codes in ten languages.

RESULTS

The result of the joint use of these two classifications, as descriptors in congress to identify the concepts in texts or index the gray literature for family medicine and primary care is presented here in its various pilot uses. The validity and generalizability of 3CGP appears to be good in the light of the translations already carried out by colleagues around the world and of the applicability of the method in the two sides of the Atlantic. However the reproducibility and the inter-coder variations still remain to be tested for Q-codes. Maintenance remains an issue.

CONCLUSION

This method highlights the conceptual extension, the complexity and the dynamics of the role of general practitioner and family doctor as well as of primary care physician.

The rendering of human phenotype and rare diseases in ICD-11

ICD-11 (International Classification of Diseases, 11th Revision) is the next major revision of the ICD by the World Health Organization (WHO). ICD-11 differs dramatically from historical versions, as it is based on an underlying semantic network of terms and meaning, called the Foundation. To function as a mutually exclusive and exhaustive statistical classification, ICD-11 creates derivative linearizations from the network that is a monohierarchy with residual categories such as Not Elsewhere Classified. ICD-11 also introduces the widespread post-coordination of terms, which allows for highly expressive representation of detailed patient descriptions. Phenotyping features are included in many subchapters or the signs and symptoms chapter. Composite phenotype descriptions of specific presentations or syndromes can be represented though post-coordination. Rare diseases are well represented in the Foundation, though not all appear in the relatively shallow linearization hierarchies.

Assessing the accuracy of using diagnostic codes from administrative data to infer antidepressant treatment indications: a validation study

PURPOSE

To assess the accuracy of using diagnostic codes from administrative data to infer treatment indications for antidepressants prescribed in primary care.

METHODS

Validation study of administrative diagnostic codes for 13 plausible indications for antidepressants compared with physician-documented treatment indications from an indication-based electronic prescribing system in Quebec, Canada. The analysis included all antidepressant prescriptions written by primary care physicians between January 1, 2003 and December 31, 2012 using the electronic prescribing system. Patient prescribed antidepressants were linked to physician claims and hospitalization data to obtain all diagnoses recorded in the past year.

RESULTS

Diagnostic codes had poor sensitivity for all treatment indications, ranging from a high of only 31.2% (95% CI, 26.8%-35.9%) for anxiety/stress disorders to as low as 1.3% (95% CI, 0.0%-5.2%) for sexual dysfunction. Sensitivity was notably worse among older patients and patients with more chronic comorbidities. Physician claims data were a better source of diagnostic codes for antidepressant treatment indications than hospitalization data.

CONCLUSIONS

Administrative diagnostic codes are poor proxies for antidepressant treatment indications. Future work should determine whether the use of other variables in administrative data besides diagnostic codes can improve the ability to predict antidepressant treatment indications.

Sensitivity of Claims-Based Algorithms to Ascertain Smoking Status More Than Doubled with Meaningful Use

BACKGROUND

The "meaningful use of certified electronic health record" policy requires eligible professionals to record smoking status for more than 50% of all individuals aged 13 years or older in 2011 to 2012.

OBJECTIVES

To explore whether the coding to document smoking behavior has increased over time and to assess the accuracy of smoking-related diagnosis and procedure codes in identifying previous and current smokers.

METHODS

We conducted an observational study with 5,423,880 enrollees from the year 2009 to 2014 in the Truven Health Analytics database. Temporal trends of smoking coding, sensitivity, specificity, positive predictive value, and negative predictive value were measured.

RESULTS

The rate of coding of smoking behavior improved significantly by the end of the study period. The proportion of patients in the claims data recorded as current smokers increased 2.3-fold and the proportion of patients recorded as previous smokers increased 4-fold during the 6-year period. The sensitivity of each International Classification of Diseases, Ninth Revision, Clinical Modification code was generally less than 10%. The diagnosis code of tobacco use disorder (305.1X) was the most sensitive code (9.3%) for identifying smokers. The specificities of these codes and the Current Procedural Terminology codes were all more than 98%.

CONCLUSIONS

A large improvement in the coding of current and previous smoking behavior has occurred since the inception of the meaningful use policy. Nevertheless, the use of diagnosis and procedure codes to identify smoking behavior in administrative data is still unreliable. This suggests that quality improvements toward medical coding on smoking behavior are needed to enhance the capability of claims data for smoking-related outcomes research.

Chart validation of inpatient International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) administrative diagnosis codes for venous thromboembolism (VTE) among intravenous immune globulin (IGIV) users in the Sentinel Distributed Database

The Sentinel Distributed Database (SDD) is a database of patient administrative healthcare records, derived from insurance claims and electronic health records, sponsored by the US Food and Drug Administration for evaluation of medical product outcomes. There is limited information on the validity of diagnosis codes for acute venous thromboembolism (VTE) in the SDD and administrative healthcare data more generally.In this chart validation study, we report on the positive predictive value (PPV) of inpatient administrative diagnosis codes for acute VTE-pulmonary embolism (PE) or lower-extremity or site-unspecified deep vein thrombosis (DVT)-within the SDD. As part of an assessment of thromboembolic adverse event risk following treatment with intravenous immune globulin (IGIV), charts were obtained for 75 potential VTE cases, abstracted, and physician-adjudicated.VTE status was determined for 62 potential cases. PPVs for lower-extremity DVT and/or PE were 90% (95% CI: 73-98%) for principal-position diagnoses, 80% (95% CI: 28-99%) for secondary diagnoses, and 26% (95% CI: 11-46%) for position-unspecified diagnoses (originating from physician claims associated with an inpatient stay). Average symptom onset was 1.5 days prior to hospital admission (range: 19 days prior to 4 days after admission).PPVs for principal and secondary VTE discharge diagnoses were similar to prior study estimates. Position-unspecified diagnoses were less likely to represent true acute VTE cases.

Validation of intellectual disability coding through hospital morbidity records using an intellectual disability population-based database in Western Australia

OBJECTIVES

To investigate how well intellectual disability (ID) can be ascertained using hospital morbidity data compared with a population-based data source.

DESIGN, SETTING AND PARTICIPANTS

All children born in 1983-2010 with a hospital admission in the Western Australian Hospital Morbidity Data System (HMDS) were linked with the Western Australian Intellectual Disability Exploring Answers (IDEA) database. The International Classification of Diseases hospital codes consistent with ID were also identified.

MAIN OUTCOME MEASURES

The characteristics of those children identified with ID through either or both sources were investigated.

RESULTS

Of the 488 905 individuals in the study, 10 218 (2.1%) were identified with ID in either IDEA or HMDS with 1435 (14.0%) individuals identified in both databases, 8305 (81.3%) unique to the IDEA database and 478 (4.7%) unique to the HMDS dataset only. Of those unique to the HMDS dataset, about a quarter (n=124) had died before 1 year of age and most of these (75%) before 1 month. Children with ID who were also coded as such in the HMDS data were more likely to be aged under 1 year, female, non-Aboriginal and have a severe level of ID, compared with those not coded in the HMDS data. The sensitivity of using HMDS to identify ID was 14.7%, whereas the specificity was much higher at 99.9%.

CONCLUSION

Hospital morbidity data are not a reliable source for identifying ID within a population, and epidemiological researchers need to take these findings into account in their study design.

A Comprehensive Approach to Convert a Radiology Department From Coding Based on International Classification of Diseases, Ninth Revision, to Coding Based on International Classification of Diseases, Tenth Revision

PURPOSE

The purpose of this study was to adapt our radiology reports to provide the documentation required for specific International Classification of Diseases, tenth rev (ICD-10) diagnosis coding.

MATERIALS AND METHODS

Baseline data were analyzed to identify the reports with the greatest number of unspecified ICD-10 codes assigned by computer-assisted coding software. A two-part quality improvement initiative was subsequently implemented. The first component involved improving clinical histories by utilizing technologists to obtain information directly from the patients or caregivers, which was then imported into the radiologist's report within the speech recognition software. The second component involved standardization of report terminology and creation of four different structured report templates to determine which yielded the fewest reports with an unspecified ICD-10 code assigned by an automated coding engine.

RESULTS

In all, 12,077 reports were included in the baseline analysis. Of these, 5,151 (43%) had an unspecified ICD-10 code. The majority of deficient reports were for radiographs (n = 3,197; 62%). Inadequacies included insufficient clinical history provided and lack of detailed fracture descriptions. Therefore, the focus was standardizing terminology and testing different structured reports for radiographs obtained for fractures. At baseline, 58% of radiography reports contained a complete clinical history with improvement to >95% 8 months later. The total number of reports that contained an unspecified ICD-10 code improved from 43% at baseline to 27% at completion of this study (P < .0001).

CONCLUSION

The number of radiology studies with a specific ICD-10 code can be improved through quality improvement methodology, specifically through the use of technologist-acquired clinical histories and structured reporting.

Evaluating the Impact of Incorrect Diabetes Coding on the Performance of Multivariable Prediction Models

The use of electronic health records for risk prediction models requires a sufficient quality of input data to ensure patient safety. The aim of our study was to evaluate the influence of incorrect administrative diabetes coding on the performance of a risk prediction model for delirium, as diabetes is known to be one of the most relevant variables for delirium prediction. We used four data sets varying in their correctness and completeness of diabetes coding as input for different machine learning algorithms. Although there was a higher prevalence of diabetes in delirium patients, the model performance parameters did not vary between the data sets. Hence, there was no significant impact of incorrect diabetes coding on the performance for our model predicting delirium.

Experts' opinion about the primary headache diagnostic criteria of the ICHD-3rd edition beta in children and adolescents

BACKGROUND

The 2013 International Classification of Headache Disorders-3 (ICHD-3) was published in a beta version to allow the clinicians to confirm the validity of the criteria or to suggest improvements based on field studies. The aim of this work was to review the Primary Headache Disorders Section of ICHD-3 beta data on children and adolescents (age 0-18 years), and to suggest changes, additions, and amendments.

METHODS

Several experts in childhood headache across the world applied different aspects of ICHD-3 beta in their normal clinical practice. Based on their personal experience and the literature available on pediatric headache, they made observations and proposed suggestions for the primary headache disorders section of ICHD-3 beta data on children and adolescents.

RESULTS

Some headache disorders in children have specific features which are different from those seen in adults and which should be acknowledged and considered. Some features in children were found to be age-dependent: clinical characteristics, risks factors and etiologies have a strong bio psycho-social basis in children and adolescents making primary headache disorders in children distinct from those in adults.

CONCLUSIONS

Several recommendations are presented in order to make ICHD-3 more appropriate for use with children.

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

Retrospective studies using large databases serve a major purpose in providing evidence in the current literature. However, the quality of medical coding is highly variable. This retrospective cohort study aimed to evaluate the documentation regarding the diagnosis of heterotopic ossification (HO) and the implications it may have for conducting retrospective research using electronic medical records (EMRs). A retrospective chart review using the EMR was performed to identify all patients with a diagnosis of HO within 7 university-affiliated hospital facilities. A limited data set request was conducted for all patients with HO-specific International Classification of Diseases, Ninth Revision (ICD-9) codes and additional nonspecific musculoskeletal codes to capture patients with HO who were improperly coded. A total of 522 patients were identified-26 patients with specific HO codes and 496 patients with nonspecific codes. Imaging and clinical notes were inspected for evidence and location of HO, and histories were reviewed for traumatic injury mechanism. Two-thirds of the patients with HO were discovered by reviewing miscellaneous musculoskeletal ICD-9 codes. Thirty-eight percent of the patients with an HO-specific ICD-9 code had no evidence of HO in their EMR. Thirty-three patients had a clinical history of a traumatic injury preceding HO formation, but only 16 of the 33 had documented ICD-9 codes for the injury. The utility of databases in retrospective research is dependent on the integrity of the coding. This study questions the use of retrospective reviews for patients with uncommon diagnoses and shows how painstaking verification may be necessary to ensure that research conclusions are based on accurate data. [Orthopedics. 2017; 40(4):237-241.].

Medium- and long-term prognostic validity of competing classification proposals for the former somatoform disorders

BACKGROUND

DSM-5 introduced a fundamental revision of the category of somatoform disorders, which resulted in the new somatic symptom disorder (SSD) and related disorders. However, prognostic validity of SSD remains unclear, while other classification proposals, such as bodily distress disorder (BDD) or polysymptomatic distress disorder (PSDD), might be promising alternatives for the new ICD-11. Therefore, the comparison of the different approaches concerning long-term prognosis of disorder-relevant factors is of special interest.

METHOD

In a longitudinal design (baseline, 1-year, and 4-year follow-up), the three proposals (SSD, BDD, PSDD) were compared in an age-representative sample of the German general population (N = 321). To this end, the baseline sample was divided into three independent pairs of groups (with/without SSD, with/without BDD, with/without PSDD). It was tested how well each approach differentiated with regard to medium- and long-term healthcare utilization, number of symptoms, and impairment.

RESULTS

Criteria for BDD distinguished best with regard to future healthcare utilization resulting in a large-sized effect (f = 0.44) for the difference between persons with and without BDD, while SSD and PSDD revealed only medium-sized effects (f = 0.28 and f = 0.32) between subjects with and without diagnosis. The three proposals distinguished equally well with regard to future subjective impairment (between f = 0.39 and f = 0.41) and the number of reported symptoms (between f = 0.77 and f = 0.83).

CONCLUSION

In accordance with our data regarding prognostic validity, the current draft of the WHO group is based on the BDD proposal. However, existing limitations and weaknesses of the present proposal for the ICD-11 are further discussed.

Diabetes Complications Severity Index (DCSI)-Update and ICD-10 translation

AIMS

The Diabetes Complications Severity Index (DCSI) converts diagnostic codes and laboratory results into a 14-level metric quantifying the long-term effects of diabetes on seven body systems. Adoption of the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) necessitates translation from ICD-9-CM and creates refinement opportunities.

METHODS

ICD-9 codes for secondary and primary diabetes plus all five ICD-10 diabetes categories were incorporated into an updated tool. Additional modifications were made to improve the accuracy of severity assignments.

SUBJECTS

The tools were tested in a Medicare Advantage population.

RESULTS

In the type 2 subpopulation, prevalence steadily declined with increasing score according to the updated DCSI tool, whereas the original tool resulted in an aberrant local prevalence peak at DCSI = 2. In the type 1 subpopulation, score prevalence was greater in type 1 versus type 2 subpopulations (3 versus 0) according to both instruments. Both instruments predicted current-year inpatient admissions risk and near-future mortality, using either purely ICD-9 data or a mix of ICD-9 and ICD-10 data.

DISCUSSION

While the performance of the tool with purely ICD-10 data has yet to be evaluated, this updated tool makes assessment of diabetes patient severity and complications possible in the interim.

[Guidelines for the use of the International Classification of Radiographs of Pneumoconioses of the International Labour Office (ILO): Substantial changes in the currrent edition]

The International Classification of Radiographs of Pneumoconioses is the scheme worked out by the International Labour Office in Geneva (ILO), to register radiographic chest abnormalities in a well-ordered, reproducible and comparable way. It is used for diagnosing abnormalities caused by dust exposure. Guidelines for the use of the ILO International Classification of Radiographs of Pneumoconioses contain detailed information and recommendations on how to use the classification, as well as how the chest X-ray examination should be performed and recorded. To facilitate the diagnosis of observed abnormalities the classification is completed by the set of standard radiograms illustrating typical irregularities referring to lungs and pleura, included in the classification. The article presents the key information on classification and the most important amendments adopted in the 2000 and 2011 ILO guidelines revisions. These changes refer to radiographs quality assessment, the way of presenting abnormalities registered in standard radiographs (QUAD set, digital images) and registration of failures not related to dust exposure. Particularly important complements result from the development of radiological imaging techniques. They are concerned about the classification of radiographic images of the chest recorded digitally. Med Pr 2016;67(6):833-837.

Diagnostic Coding for Epilepsy

Accurate coding is an important function of neurologic practice. This contribution to Continuum is part of an ongoing series that presents helpful coding information along with examples related to the issue topic. Tips for diagnosis coding, Evaluation and Management coding, procedure coding, or a combination are presented, depending on which is most applicable to the subject area of the issue.

Variability in Standard Outcomes of Posterior Lumbar Fusion Determined by National Databases

OBJECTIVE

National databases are used with increasing frequency in spine surgery literature to evaluate patient outcomes. The differences between individual databases in relationship to outcomes of lumbar fusion are not known. We evaluated the variability in standard outcomes of posterior lumbar fusion between the University HealthSystem Consortium (UHC) database and the Healthcare Cost and Utilization Project National Inpatient Sample (NIS).

METHODS

NIS and UHC databases were queried for all posterior lumbar fusions (International Classification of Diseases, Ninth Revision code 81.07) performed in 2012. Patient demographics, comorbidities (including obesity), length of stay (LOS), in-hospital mortality, and complications such as urinary tract infection, deep venous thrombosis, pulmonary embolism, myocardial infarction, durotomy, and surgical site infection were collected using specific International Classification of Diseases, Ninth Revision codes.

RESULTS

Analysis included 21,470 patients from the NIS database and 14,898 patients from the UHC database. Demographic data were not significantly different between databases. Obesity was more prevalent in UHC (P = 0.001). Mean LOS was 3.8 days in NIS and 4.55 in UHC (P < 0.0001). Complications were significantly higher in UHC, including urinary tract infection, deep venous thrombosis, pulmonary embolism, myocardial infarction, surgical site infection, and durotomy. In-hospital mortality was similar between databases.

CONCLUSIONS

NIS and UHC databases had similar demographic patient populations undergoing posterior lumbar fusion. However, the UHC database reported significantly higher complication rate and longer LOS. This difference may reflect academic institutions treating higher-risk patients; however, a definitive reason for the variability between databases is unknown. The inability to precisely determine the basis of the variability between databases highlights the limitations of using administrative databases for spinal outcome analysis.