Capturing diagnosis-timing in ICD-coded hospital data: recommendations from the WHO ICD-11 topic advisory group on quality and safety.

PURPOSE: To develop a consensus opinion regarding capturing diagnosis-timing in coded hospital data. METHODS: As part of the World Health Organization International Classification of Diseases-11th Revision initiative, the Quality and Safety Topic Advisory Group is charged with enhancing the capture of quality and patient safety information in morbidity data sets. One such feature is a diagnosis-timing flag. The Group has undertaken a narrative literature review, scanned national experiences focusing on countries currently using timing flags, and held a series of meetings to derive formal recommendations regarding diagnosis-timing reporting. RESULTS: The completeness of diagnosis-timing reporting continues to improve with experience and use; studies indicate that it enhances risk-adjustment and may have a substantial impact on hospital performance estimates, especially for conditions/procedures that involve acutely ill patients. However, studies suggest that its reliability varies, is better for surgical than medical patients (kappa in hip fracture patients of 0.7-1.0 versus kappa in pneumonia of 0.2-0.6) and is dependent on coder training and setting. It may allow simpler and more precise specification of quality indicators. CONCLUSIONS: As the evidence indicates that a diagnosis-timing flag improves the ability of routinely collected, coded hospital data to support outcomes research and the development of quality and safety indicators, the Group recommends that a classification of 'arising after admission' (yes/no), with permitted designations of 'unknown or clinically undetermined', will facilitate coding while providing flexibility when there is uncertainty. Clear coding standards and guidelines with ongoing coder education will be necessary to ensure reliability of the diagnosis-timing flag.

International variation in the definition of 'main condition' in ICD-coded health data.

Hospital-based medical records are abstracted to create International Classification of Disease (ICD) coded discharge health data in many countries. The 'main condition' is not defined in a consistent manner internationally. Some countries employ a 'reason for admission' rule as the basis for the main condition, while other countries employ a 'resource use' rule. A few countries have recently transitioned from one of these approaches to the other. The definition of 'main condition' in such ICD data matters when it is used to define a disease cohort to assign diagnosis-related groups and to perform risk adjustment. We propose a method of harmonizing the international definition to enable researchers and international organizations using ICD-coded health data to aggregate or compare hospital care and outcomes across countries in a consistent manner. Inter-observer reliability of alternative harmonization approaches should be evaluated before finalizing the definition and adopting it worldwide.

[ICD-10 adaptation of 15 Agency for Healthcare Research and Quality patient safety indicators]. / Adaptation au codage CIM-10 de 15 indicateurs de la sécurité des patients proposés par l'Agence étasunienne pour la recherche et la qualité des soins de santé (AHRQ).

BACKGROUND: In the United States, the Agency for Healthcare Research and Quality (AHRQ) has developed 20 Patient Safety Indicators (PSIs) to measure the occurrence of hospital adverse events from medico-administrative data coded according to the ninth revision of the international classification of disease (ICD-9-CM). The adaptation of these PSIs to the WHO version of ICD-10 was carried out by an international consortium. METHODS: Two independent teams transcoded ICD-9-CM diagnosis codes proposed by the AHRQ into ICD-10-WHO. Using a Delphi process, experts from six countries evaluated each code independently, stating whether it was "included", "excluded" or "uncertain". During a two-day meeting, the experts then discussed the codes that had not obtained a consensus, and the additional codes proposed. RESULTS: Fifteen PSIs were adapted. Among the 2569 proposed diagnosis codes, 1775 were unanimously adopted straightaway. The 794 remaining codes and 2541 additional codes were discussed. Three documents were prepared: (1) a list of ICD-10-WHO codes for the 15 adapted PSIs; (2) recommendations to the AHRQ for the improvement of the nosological frame and the coding of PSI with ICD-9-CM; (3) recommendations to the WHO to improve ICD-10. CONCLUSIONS: This work allows international comparisons of PSIs among the countries using ICD-10. Nevertheless, these PSIs must still be evaluated further before being broadly used.

Thyroid cancer in pregnancy.

OBJECTIVE: To compare stage at diagnosis, treatment and survival among pregnant women with thyroid cancer to non-pregnant women with thyroid cancer, and to assess the impact of treatment on maternal and perinatal outcomes. METHODS: A database containing maternal and newborn discharge records linked to the California Cancer Registry was queried to obtain information on all thyroid cancers from 1991-1999. Women with thyroid cancer occurring during pregnancy were compared to age-matched non-pregnant women with thyroid cancer. RESULTS: 595 cases of thyroid cancers were identified (129 antepartum and 466 postpartum). About 64% of thyroid cancers were diagnosed at stage 2 among pregnant women versus 58% among non-pregnant controls. The odds of thyroid cancer were 1.5 times higher among Asian/Pacific Islanders than among Non-Hispanic White women. Pregnancy had no significant effect on mortality after diagnosis of thyroid cancer. Thyroidectomy during pregnancy was not associated with adverse maternal or neonatal outcomes. CONCLUSIONS: Thyroid cancer discovered during or after pregnancy does not appear to have a significant impact on the prognosis of the disease.

Developmental differences between cation-independent and cation-dependent mannose-6-phosphate receptors in rat brain at perinatal stages.

Mannose-6-phosphate receptors (MPRs) play a role in the selective transport of macromolecules bearing mannose-6-phosphate residue to lysosomes. To date, two types of MPRs have been described in most of cells and tissues: the cation-dependent (CD-MPR) and cation-independent mannose-6-phosphate receptor (CI-MPR). In order to elucidate their possible role in the central nervous system, the expression and binding properties of both MPRs were studied in rat brain along perinatal development. It was observed that the expression of CI-MPR decreases progressively from fetuses to adults, while the CD-MPR increases around the 10th day of birth, and maintains these values up to adulthood. Binding assays showed differences in the Bmax and KD values between the ages studied, and they did not correlate with the expression levels of both MPRs. Variations in lysosomal enzyme activities and expression of phosphomannosylated ligands during development correlated more with CD-MPR than with CI-MPR expression. These results suggest that both receptors play a different role in rat brain during perinatal development, being CD-MPR mostly involved in lysosome maturation.

Mannose-6-phosphate receptors as a molecular indicator of maturation of epididymal sperm.

This review discusses some of the changes in sperm during maturation within the context of current concepts of membrane structure and fertilization. Mammalian sperm are surrounded by a limiting plasma membrane that undergoes remodeling during passage through the epididymis. This process confers on the gamete vigorous motility and the ability to fertilize the egg. The repositioning of some surface proteins may follow redistribution of lipids in the plasmalemma, and thus represent a critical step in the maturation of the gametes. Among the various affected proteins of the sperm plasmalemma, mannose-6-phosphate receptors undergo redistribution as the gametes transit through the epididymal duct. The authors summarize their studies of the redistribution of phosphomannosyl receptors during maturation of sperm and discuss possible roles of these glycoproteins in the fertilizing capability of sperm.

Breast cancer stage at diagnosis in relation to duration of medicaid enrollment.

BACKGROUND: Stage at diagnosis has been used to compare the quality of cancer screening services by health insurance type, using membership at diagnosis or treatment. This study evaluates breast cancer stage among women on Medi-Cal, California's Medicaid program, in relation to duration of coverage to assess the impact of including women with recently acquired benefits in the Medi-Cal group. METHODS: Breast cancers diagnosed in 1993 among women ages 30 to 64 were obtained from the statewide, population-based cancer registry and linked to Medi-Cal enrollment files. Women on Medi-Cal when diagnosed were categorized based on months covered during the 12 months preceding diagnosis (12, 1-11, or none), and compared with all other women with breast cancer. Logistic regression models measured the effect of duration of Medi-Cal coverage on the odds of late-stage disease, controlling for demographic, socioeconomic, health access, and tumor characteristics. RESULTS: Among women with Medi-Cal benefits when diagnosed, 18% were not covered during the year preceding diagnosis, and late-stage disease was common among these women. The odds ratio for late-stage disease among all women on Medi-Cal was 1.67 (95% CI 1.41, 1.97), but was reduced by 42% to 1.39 (95% CI 1.15, 1.67) when women without benefits before diagnosis were excluded from the Medi-Cal group. CONCLUSIONS: Women with Medi-Cal benefits before diagnosis were more likely to be diagnosed with late-stage disease than other women with breast cancer. However, the practice of assigning health insurance status based on enrollment at diagnosis underestimates the effect of access to breast cancer screening through Medicaid.

Does "mainstreaming" guarantee access to care for medicaid recipients with asthma?

OBJECTIVE: Recent reforms in the federal Medicaid program have attempted to integrate beneficiaries into the mainstream by providing them with managed care options. However, the effects of mainstreaming have not been systematically evaluated. DESIGN: Cross-sectional survey. SETTING/PARTICIPANTS: A sample of 478 adult, nonelderly asthmatics followed by a large Northern California medical group. MEASUREMENTS AND MAIN RESULTS: We examined differences in self-reported access by insurance status. Compared to patients with other forms of insurance, patients covered by the state's Medicaid program (Medi-Cal) were more likely to report access problems for asthma-related care, including difficulties in reaching a health care provider by telephone, obtaining a clinic appointment, and obtaining asthma medication. Adjusting for relevant clinical and sociodemographic variables, Medi-Cal patients were more likely to report at least one access problem compared to non-Medi-Cal patients (adjusted odds ratio [AOR], 3.34; 95% confidence interval [CI], 1.43 to 7.80). Patients reporting at least one access problem were also more likely to have made at least one asthma-related emergency department visit within the past year (AOR, 4.84; 95% CI, 2.41 to 9.72). Reported barriers to care did not translate into reduced patient satisfaction. CONCLUSIONS: Within this population of Medicaid patients, the provision of health insurance and care within the mainstream of an integrated health system was no guarantee of equal access as perceived by the patients themselves.

Predictors of rehospitalization for symptomatic venous thromboembolism after total hip arthroplasty.

BACKGROUND: Recent studies have shown that symptomatic venous thromboembolism after total hip arthroplasty most commonly develops after the patient is discharged from the hospital. Risk factors associated with these symptomatic thromboembolic events are not well defined. METHODS: Using administrative data from the California Medicare records for 1993 through 1996, we identified 297 patients 65 years of age or older who were rehospitalized for thromboembolism within three months after total hip arthroplasty. We compared demographic, surgical, and medical variables potentially associated with the development of thromboembolism in these patients and 592 unmatched controls. RESULTS: A total of 89.6 percent of patients with thromboembolism and 93.8 percent of control patients were treated with pneumatic compression, warfarin, enoxaparin, or unfractionated heparin, alone or in combination. In addition, 22.2 percent and 29.7 percent, respectively, received warfarin after discharge. A body-mass index (the weight in kilograms divided by the square of the height in meters) of 25 or greater was associated with rehospitalization for thromboembolism, with an odds ratio of 2.5 (95 percent confidence interval, 1.8 to 3.4). In a multivariate model, the only prophylactic regimens associated with a reduced risk of thromboembolism were pneumatic compression in patients with body-mass indexes of less than 25 (odds ratio, 0.3; 95 percent confidence interval, 0.2 to 0.6) and warfarin treatment after discharge (odds ratio, 0.6; 95 percent confidence interval, 0.4 to 1.0). CONCLUSIONS: In patients who underwent total hip arthroplasty, a body-mass index of 25 or greater was associated with subsequent hospitalization for thromboembolism. Pneumatic compression in patients with a body-mass index of less than 25 and prophylaxis with warfarin after discharge were independently protective against thromboembolism.

Ethnic differences in adolescent substance initiation sequences.

OBJECTIVES: To evaluate ethnic differences in the initiation sequences of tobacco, alcohol, marijuana, and cocaine use among US high school students and to determine if ethnicity is a predictor of progression from licit to illicit substances or initiation of illicit substances before licit substances. DESIGN: Cross-sectional analyses of the Centers for Disease Control and Prevention's 1995 Youth Risk Behavior Survey. SETTING: US high schools. PARTICIPANTS: A total of 8550 high school students randomly selected by cluster design. MAIN OUTCOME MEASURES: Respondents were categorized based on self-reported sequence of initiating substances as follows: none, licit substances only, licit substances then illicit substances (typical), illicit substances first (reverse), and licit and illicit substances at the same time (concurrent). RESULTS: Adjusting for age, maternal education, and region, progression from licit to illicit substances was significantly associated with black ethnicity (odds ratio [OR], 1.5; 95% confidence interval [CI], 1.04-2.1) and male sex (OR, 1.4; 95% CI, 1.2-1.6). Black male and Latino female students whose mothers completed at least high school were more likely than white students with similarly educated mothers to initiate illicit substances before licit substances (OR, 3.0; 95% CI, 1.7-5.3; and OR, 5.9; 95% CI, 1.7-20; respectively). Similar trends were noted for the concurrent sequence. CONCLUSIONS: The pattern of initiating tobacco, alcohol, marijuana, and cocaine use differs by ethnicity. Maternal education may be a proxy variable for other significant risk factors.

Changes in distribution of phosphomannosyl receptors during maturation of rat spermatozoa.

The aim of the present work was to study the distribution of the cation-independent (CI) and cation-dependent (CD) mannose-6-phosphate receptors (MPRs) in spermatozoa obtained from either rete testis or three regions of rat epididymis. We observed that both receptors underwent changes in distribution as spermatozoa passed from rete testis to cauda epididymis. CI-MPR was concentrated in the dorsal region of the head in rete testis sperm and that this labeling extended to the equatorial segment of epididymal spermatozoa. CD-MPR, however, changed from a dorsal distribution in rete testis, caput, and corpus to a double labeling on the dorsal and ventral regions in cauda spermatozoa. The percentages of spermatozoa that showed staining for either CI-MPR or CD-MPR increased from rete testis to epididymis. The observed changes were probably the result of a redistribution during transit rather than an unmasking of receptors. The fluorescence corresponding to CD-MPR and CI-MPR on the dorsal region disappeared when caudal spermatozoa underwent the acrosomal reaction. Receptors were localized on the plasmalemma of spermatozoa, as observed by immunoelectron microscopy. Changes in distribution may be related to a maturation process, which suggests new roles for the phosphomannosyl receptors.

Methods for diagnosing onychomycosis: a comparative study and review of the literature.

OBJECTIVE: To identify the sensitivity of several readily available diagnostic tests for onychomycosis. DESIGN: Cross-sectional study. SETTING: Dermatology and podiatry departments at a teaching hospital. PATIENTS: Sixty-three adult men and women with a clinical examination highly suggestive of onychomycosis. MAIN OUTCOME MEASURES: Sensitivity of each test and of several test combinations. RESULTS: Nail samples underwent 6 diagnostic tests. Routine histopathologic examination with periodic acid-Schiff stain (PAS) (PATHPAS) was 85% sensitive. Sensitivities for potassium hydroxide dissolution and centrifugation combined with PAS, fluorescent brightener, or chlorazol black E were 57%, 53%, and 53%, respectively. Culture on Sabouraud agar withchloramphenicol and cycloheximide (Mycosel agar) was 32% sensitive; on Littman-oxgall agar, 23% sensitive. The most sensitive combination of tests, both culture methods plus PATHPAS, was 94% sensitive (not statistically different from the sensitivity of PATHPAS alone [P = .26]). CONCLUSIONS: When onychomycosis is suspected clinically, PATHPAS of the nail is the single most sensitive of the diagnostic tests we evaluated. Because it is quickly performed and relatively operator independent, PATHPAS is practical for clinical and research purposes. Further study is needed to determine if sensitivity may be enhanced by combining PATHPAS with cultures obtained by several collection methods (clipping, curettage, and shaving). Such combinations may serve as sensitive and efficient strategies for diagnosing onychomycosis.

A population-based study of the effectiveness of inferior vena cava filter use among patients with venous thromboembolism.

BACKGROUND: There are few population-based data regarding the effectiveness of inferior vena cava filter use in the prevention of symptomatic pulmonary embolism. OBJECTIVE: To determine the 1-year cumulative incidence of rehospitalization for venous thrombosis or pulmonary embolism among patients with thromboembolism treated with a vena cava filter compared with the incidence in a control population with thromboembolism. PATIENTS AND METHODS: Population-based retrospective analysis of linked hospital discharge abstracts in California. From January 1, 1991, through December 30, 1995, 3632 patients were treated with a filter and 64,333 controls were admitted with a principal diagnosis of venous thromboembolism. RESULTS: Filter-treated patients had significantly greater comorbidity, with a higher frequency of previous pulmonary embolism, recent major bleeding, malignant neoplasm, and stroke. Patients who initially manifested pulmonary embolism were significantly more likely to be rehospitalized for pulmonary embolism than patients with an initial diagnosis of venous thrombosis alone, among filter-treated patients (relative risk, 6.72; 95% confidence interval, 3.61-12.49) and controls (relative risk, 5.30; 95% confidence interval, 4.61-6.10). Risk-adjusted proportional hazards modeling showed no significant difference between filter-treated patients and controls in the relative hazard of rehospitalization for pulmonary embolism. However, filter placement was associated with a significantly higher relative hazard of rehospitalization for venous thrombosis among patients who initially manifested pulmonary embolism (relative hazard, 2.62; 95% confidence interval, 2.09-3.29), but not among those who presented with venous thrombosis (relative hazard, 1.14; 95% confidence interval, 0.92-1.43). CONCLUSIONS: Insertion of a vena cava filter was not associated with a significant reduction in the 1-year incidence of rehospitalization for pulmonary embolism. Use of a filter was associated with a higher incidence of rehospitalization for venous thrombosis, but only among patients who initially manifested pulmonary embolism. A prospective clinical study is needed to determine the efficacy of filter use among patients with pulmonary embolism who do not meet strict guidelines for insertion of a vena cava filter.

Sociodemographic factors and the assignment of do-not-resuscitate orders in patients with acute myocardial infarctions.

OBJECTIVES: This study examined the impact of sociodemographic and clinical factors, measured at the individual or ecological (zip code) level, on the assignment of do-not-resuscitate (DNR) orders. DESIGN: This was a retrospective study (analysis of secondary data). SUBJECTS: We used a probability sample of 974 patients admitted to 30 medium to large California hospitals with acute myocardial infarctions in 1990 to 1991; the sample was originally designed to validate risk adjustment with administrative data. METHODS: Multivariate logistic regression was used to adjust DNR assignment for age, gender, race, probability of death, functional impairments, payment source, hospital teaching status, and ecological measures of educational attainment, home ownership, and income. RESULTS: DNR assignment was inversely associated with black race and positively associated with age, probability of death, cognitive impairment, and poor nutritional status. When the probability of death was very low, DNR orders were assigned less frequently to men than to women (odds ratio [OR], 0.4; 95% confidence interval [CI], 0.2 to 0.7 at probability of death = 0.10). However, men were significantly more likely to receive a DNR order than women when the probability of death was very high (OR, 4.4; 95% CI, 1.2 to 16.3 at probability of death = 0.90). CONCLUSIONS: Older, white, sicker, or functionally impaired patients receive DNR orders more often than younger, black, healthier, or functionally intact patients do. Adjusting for these factors, DNR assignment is associated with gender through an interaction involving the probability of death. Future studies should reexamine the impact of these factors on DNR assignment and explore the role of patient values and patient-physician communication barriers.

Risk-adjusting acute myocardial infarction mortality: are APR-DRGs the right tool?

OBJECTIVE: To determine if a widely used proprietary risk-adjustment system, APR-DRGs, misadjusts for severity of illness and misclassifies provider performance. DATA SOURCES: (1) Discharge abstracts for 116,174 noninstitutionalized adults with acute myocardial infarction (AMI) admitted to nonfederal California hospitals in 1991-1993; (2) inpatient medical records for a stratified probability sample of 974 patients with AMIs admitted to 30 California hospitals between July 31, 1990 and May 31, 1991. STUDY DESIGN: Using the 1991-1993 data set, we evaluated the predictive performance of APR-DRGs Version 12. Using the 1990/1991 validation sample, we assessed the effect of assigning APR-DRGs based on different sources of ICD-9-CM data. DATA COLLECTION/EXTRACTION METHODS: Trained, blinded coders reabstracted all ICD-9-CM diagnoses and procedures, and established the timing of each diagnosis. APR-DRG Risk of Mortality and Severity of Illness classes were assigned based on (1) all hospital-reported diagnoses, (2) all reabstracted diagnoses, and (3) reabstracted diagnoses present at admission. The outcome variables were 30-day mortality in the 1991-1993 data set and 30-day inpatient mortality in the 1990/1991 validation sample. PRINCIPAL FINDINGS: The APR-DRG Risk of Mortality class was a strong predictor of death (c = .831-.847), but was further enhanced by adding age and sex. Reabstracting diagnoses improved the apparent performance of APR-DRGs (c = .93 versus c = .87), while using only the diagnoses present at admission decreased apparent performance (c = .74). Reabstracting diagnoses had less effect on hospitals' expected mortality rates (r = .83-.85) than using diagnoses present at admission instead of all reabstracted diagnoses (r = .72-.77). There was fair agreement in classifying hospital performance based on these three sets of diagnostic data (K = 0.35-0.38). CONCLUSIONS: The APR-DRG Risk of Mortality system is a powerful risk-adjustment tool, largely because it includes all relevant diagnoses, regardless of timing. Although some late diagnoses may not be preventable, APR-DRGs appear suitable only if one assumes that none is preventable.