Positive predictive values of ICD-9 codes to identify patients with stroke or TIA.

OBJECTIVES: To determine the positive predictive values of inpatient and outpatient ICD-9 codes and status code V12.54 for identifying confirmed history of stroke or transient ischemic attack (cerebral event) among patients within a managed care organization. STUDY DESIGN: Retrospective, cohort study. METHODS: Inpatient hospital claims and outpatient visit records were used to identify patients with ICD-9 codes (430.XX to 438.XX) or status code V12.54 in the primary or secondary position recorded between January 1, 2001, and December 31, 2009. A standardized chart abstraction tool was used by trained chart abstractors blinded to the coding to confirm the cerebral event and classify stroke type. Positive predictive values (PPVs) were calculated for each code based on care setting. RESULTS: A total of 4689 patients with 10,376 unique stroke codes recorded in the administrative data were reviewed. Of these, 2785 (59.4%) patients had a confirmed cerebral event. The codes with PPV less than 90% were 434.XX, 433 .X1, and V12.54 where codes were recorded in both the inpatient and outpatient settings. Overall, inpatient-only codes produced higher PPVs; however, relatively fewer events were captured in this setting. CONCLUSIONS: Administrative ICD-9 codes 434.XX, 433.X1, and V12.54 had consistently high PPVs in identifying patients with a confirmed cerebral event. These codes could be used as part of a probabilistic approach to focus care activities on patients with the highest likelihood of a cerebral event.

Angiotensin-converting enzyme inhibitor therapy for coronary artery disease and diabetes mellitus.

OBJECTIVES: To use a population management strategy to increase the proportion of patients with coronary artery disease (CAD) and diabetes receiving target-dose angiotensin-converting enzyme (ACE) inhibitor therapy and to assess the safety and tolerability of this initiative. STUDY DESIGN: Prospective cohort. METHODS: Patients were eligible for enrollment if they were not receiving target-dose ACE inhibitor therapy. Clinical pharmacy specialists were responsible for initiation, titration, and appropriate follow-up of ACE inhibitor therapy. RESULTS: A total of 453 subjects were enrolled. Their mean age was 67.9 years and 77% were male. At baseline, 30.9% (n = 140) of eligible patients were on no ACE inhibitor therapy and no patients were at the target dose. The mean systolic blood pressure, serum creatinine, and serum potassium values were 128.0 mm Hg, 1.0 mg/dL, and 4.4 mEq/dL, respectively. At follow-up, 8.2% (n = 37; P < .001) were on no ACE inhibitor therapy and 68.7% (n = 311; P < .001) of patients had achieved the target dose. From baseline to follow-up, mean systolic blood pressure decreased 4.4 mm Hg (P < .001). Changes in serum potassium or creatinine were not clinically significant. Of the 142 subjects unable to achieve the target dose, 31 experienced hypotension, 29 did not have the dose increased because of the potential for hypotension, and 23 experienced cough. CONCLUSION: A population management approach to increasing the proportion of patients with CAD and diabetes who receive target-dose ACE inhibitor therapy was effective and safe.

Assessment of patient satisfaction with telephone and mail interventions provided by a clinical pharmacy cardiac risk reduction service.

OBJECTIVE: Kaiser Permanente of Colorado developed a population-based program, the Clinical Pharmacy Cardiac Risk Service (CPCRS), to help close the treatment gap for patients with coronary artery disease. CPCRS provides much of its care via telephone. The purpose of this study was to determine the level of satisfaction among patients in this unique service. METHODS: This was a cross-sectional survey of patients enrolled in CPCRS for at least 6 months. A sample of patients who met the inclusion criteria were chosen at random to receive the satisfaction survey via mail. Questions pertained to overall satisfaction and satisfaction with individual components of CPCRS. A Likert-type, 5-point scale was used for the majority of the questions. Analyses of the results were primarily descriptive. RESULTS: Of 1,000 surveys mailed, 491 (49.1%) were returned. The majority of respondents were male (68.5%). The average age of respondents was 71.7 (SD) 9 years. Of those surveyed, 94.6% (95% confidence interval [CI], 92.6%- 96.6%) reported being satisfied (agree or strongly agree) with the care they received for cholesterol management from their CPCRS clinical pharmacy specialist. Respondents reported that their CPCRS clinical pharmacy specialist was easy to contact (83.7%, 95% CI, 80.3%-87.1%), provided timely service (94.8%; 95% CI, 92.8%-96.8%), and addressed all questions or concerns in a way that was easy to understand (85.8%; 95% CI, 82.6%-89.0%). The majority of respondents reported that they were content receiving care over the telephone (86.7%; 95% CI, 83.5%-89.9%) and by mail (90.0%; 95% CI, 87.1%-92.9%). CONCLUSION: Overall, survey respondents indicated a high level of satisfaction with the services provided by CPCRS. Based upon patient satisfaction, the results of this survey suggest that the use of telephone and mail systems to provide patient care can allow clinical pharmacy specialists to manage a large number of patients successfully. Health care systems may wish to explore similar methods to address the needs of patients with coronary artery disease.