Audit of ethnicity data in the Waikato Hospital Patient Management System and Trauma Registry: pilot of the Hospital Ethnicity Data Audit Toolkit.

BACKGROUND: Maori are disproportionately impacted by injury in New Zealand, therefore reliable ethnicity data are essential for measuring and addressing inequities in trauma incidence, care and outcomes. AIM: To audit the quality of ethnicity data captured by the Waikato Hospital Trauma Registry and Waikato Hospital patient management system against self-identified ethnicity. METHOD: Self-identified ethnicity using the New Zealand Census ethnicity question was gathered from 100 consecutive trauma patients and compared with ethnicity recorded in their Trauma Registry record and in the hospital's patient management database. RESULTS: Twenty-nine (29%) participants self-identified as Maori, of whom six were classified as New Zealand European (NZE) only in the Trauma Registry and five as NZE on the hospital patient management database. Over half of Maori (n=18/29) reported more than one ethnicity compared with 4% (n=3/71) of non-Maori. Self-identified ethnicity matched Trauma Registry ethnicity for one quarter (n=7/29) of Maori versus 9% of non-Maori. CONCLUSIONS: The degree of misclassification of Maori ethnicity data among patients in the Waikato Trauma Registry and the Waikato Hospital patient management system highlights a need for improvements to how ethnicity data is captured within these databases and potentially many other similar entities collecting ethnicity data in New Zealand. The release of revised standardised protocols for the collection of ethnicity data is timely given the recent establishment of a national trauma registry. Without quality data, the opportunity to investigate and address ethnic inequities in trauma incidence and management is greatly compromised.

Problem list completeness in electronic health records: A multi-site study and assessment of success factors.

OBJECTIVE: To assess problem list completeness using an objective measure across a range of sites, and to identify success factors for problem list completeness. METHODS: We conducted a retrospective analysis of electronic health record data and interviews at ten healthcare organizations within the United States, United Kingdom, and Argentina who use a variety of electronic health record systems: four self-developed and six commercial. At each site, we assessed the proportion of patients who have diabetes recorded on their problem list out of all patients with a hemoglobin A1c elevation>=7.0%, which is diagnostic of diabetes. We then conducted interviews with informatics leaders at the four highest performing sites to determine factors associated with success. Finally, we surveyed all the sites about common practices implemented at the top performing sites to determine whether there was an association between problem list management practices and problem list completeness. RESULTS: Problem list completeness across the ten sites ranged from 60.2% to 99.4%, with a mean of 78.2%. Financial incentives, problem-oriented charting, gap reporting, shared responsibility, links to billing codes, and organizational culture were identified as success factors at the four hospitals with problem list completeness at or near 90.0%. DISCUSSION: Incomplete problem lists represent a global data integrity problem that could compromise quality of care and put patients at risk. There was a wide range of problem list completeness across the healthcare facilities. Nevertheless, some facilities have achieved high levels of problem list completeness, and it is important to better understand the factors that contribute to success to improve patient safety. CONCLUSION: Problem list completeness varies substantially across healthcare facilities. In our review of EHR systems at ten healthcare facilities, we identified six success factors which may be useful for healthcare organizations seeking to improve the quality of their problem list documentation: financial incentives, problem oriented charting, gap reporting, shared responsibility, links to billing codes, and organizational culture.

Coverage and accuracy of ethnicity data on three Asian ethnic groups in New Zealand.

OBJECTIVE: Detecting and eliminating ethnic disparities in access to and outcomes of healthcare relies on accurate ethnicity recording. Studies have shown that there are inaccuracies in ethnicity data in New Zealand and elsewhere. This study examined coverage and accuracy of ethnicity data for three Asian ethnic groups. METHODS: Student researchers from, or with links to, the ethnic groups concerned worked with communities to recruit participants. Names and dates of birth, length of residence in New Zealand and immigration status were recorded. Names and dates of birth were sent to the New Zealand Health Information Service, which attempted to link them with National Health Index ethnicity data. RESULTS: Only 72% of participants could be linked to an NHI number, and only 48% of those had their ethnicity recorded accurately. Linkage odds were lower for older people, and accuracy was higher for Chinese people compared to the other ethnicities. Length of residence and immigration status did not affect either coverage or accuracy. CONCLUSION: Most participants who could be linked had their ethnicity recorded in the broader category of "Asian", but accuracy was poor at the sub-group level. IMPLICATIONS: Extreme caution should be applied when examining data about sub-groups within the 'Asian' category.

How accurate is ICD coding for epilepsy?

PURPOSE: Assess the validity of ICD-9-CM and ICD-10 epilepsy coding from an emergency visit (ER) and a hospital discharge abstract database (DAD). METHODS: Two separate sources of patient records were reviewed and validated. (1) Charts of patients admitted to our seizure monitoring unit over 2 years (n = 127, ICD-10 coded records) were reviewed. Sensitivity (Sn), specificity (Sp), and positive and negative predictive values (PPV and NPV) were calculated. (2) Random sample of charts for patients seen in the ER or admitted to hospital under any services, and whose charts were coded with epilepsy or an epilepsy-like condition, were reviewed. Two time-periods were selected to allow validation of both ICD-9-CM (n = 486) and ICD-10 coded (n = 454) records. Only PPV and NPV were calculated for these records. All charts were reviewed by two physicians to confirm the presence/absence of epilepsy and compare to administrative coding. RESULTS: Sample 1: Sn, Sp, PPV, and NPV of ICD-10 epilepsy coding from the seizure monitoring unit (SMU) chart review were 99%, 70%, 85%, and 97% respectively. Sample 2: The PPV and NPV for ICD-9-CM coding from the ER database were, respectively, 99% and 97% and from the DAD were 98% and 99%. The PPV and NPV for ICD-10 coding from the ER database were, respectively, 100% and 90% and from the DAD were 98% and 99%. The epilepsy subtypes grand mal status and partial epilepsy with complex partial seizures both had PPVs >75% (ICD-9-CM and ICD-10 data). DISCUSSION: Administrative emergency and hospital discharge data have high epilepsy coding validity overall in our health region.

Sensitivity of billing claims for cardiovascular disease events among kidney transplant recipients.

BACKGROUND AND OBJECTIVES: Billing claims are increasingly examined beyond administrative functions as outcomes measures in observational research. Few studies have described the performance of billing claims as surrogate measures of clinical events among kidney transplant recipients. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: We investigated the sensitivity of Medicare billing claims for clinically verified cardiovascular diagnoses (five categories) and procedures (four categories) in a novel database linking Medicare claims to electronic medical records of one transplant program. Cardiovascular events identified in medical records for 571 Medicare-insured transplant recipients in 1991 through 2002 served as reference measures. RESULTS: Within a claims-ascertainment period spanning +/-30 d of clinically recorded dates, aggregate sensitivity of single claims was higher for case definitions incorporating Medicare Parts A and B for diagnoses and procedures (90.9%) compared with either Part A (82.3%) or Part B (84.6%) alone. Perfect capture of the four procedures was possible within +/-30 d or with short claims window expansion, but sensitivity for the diagnoses trended lower with all study algorithms (91.2% with window up to +/-90 d). Requirement for additional confirmatory diagnosis claims did not appreciably reduce sensitivity. Sensitivity patterns were similar in the early compared with late periods of the study. CONCLUSIONS: Combined use of Medicare Parts A and B billing claims composes a sensitive measure of cardiovascular events after kidney transplant. Further research is needed to define algorithms that maximize specificity as well as sensitivity of claims from Medicare and other insurers as research measures in this population.

Audit of clinical coding of major head and neck operations.

INTRODUCTION: Within the NHS, operations are coded using the Office of Population Censuses and Surveys (OPCS) classification system. These codes, together with diagnostic codes, are used to generate Healthcare Resource Group (HRG) codes, which correlate to a payment bracket. The aim of this study was to determine whether allocated procedure codes for major head and neck operations were correct and reflective of the work undertaken. HRG codes generated were assessed to determine accuracy of remuneration. PATIENTS AND METHODS: The coding of consecutive major head and neck operations undertaken in a tertiary referral centre over a retrospective 3-month period were assessed. Procedure codes were initially ascribed by professional hospital coders. Operations were then recoded by the surgical trainee in liaison with the head of clinical coding. The initial and revised procedure codes were compared and used to generate HRG codes, to determine whether the payment banding had altered. RESULTS: A total of 34 cases were reviewed. The number of procedure codes generated initially by the clinical coders was 99, whereas the revised codes generated 146. Of the original codes, 47 of 99 (47.4%) were incorrect. In 19 of the 34 cases reviewed (55.9%), the HRG code remained unchanged, thus resulting in the correct payment. Six cases were never coded, equating to pound15,300 loss of payment. CONCLUSIONS: These results highlight the inadequacy of this system to reward hospitals for the work carried out within the NHS in a fair and consistent manner. The current coding system was found to be complicated, ambiguous and inaccurate, resulting in loss of remuneration.

A review and characterization of the MDS process in nursing homes.

The Minimum Data Set (MDS) is a tool used by nursing homes for resident assessment and care planning, indicating facility quality and the extent of residents' care needs. The process by which the MDS is completed by facilities has not been empirically studied. Understanding common strategies and practices for completing the MDS helps further comprehend the validity of the MDS and its relevance for focusing on residents and implementing clinical nursing interventions. This article reports on the responses to a survey questionnaire addressing this process by a sample of nursing homes in Ohio. The MDS assessment was found to be an intensive activity requiring the commitment of multiple staff members. Most facilities employed at least one full-time coordinator for this task. The importance of training was noted by a number of facilities, and the Resident Assessment Instrument manual was highlighted as one of the most valued resources for completing this assessment.

Ascertainment of Hispanic ethnicity on California death certificates: implications for the explanation of the Hispanic mortality advantage.

OBJECTIVES: We determined the size and correlates of underascertainment of Hispanic ethnicity on California death certificates. METHODS: We used 1999 to 2000 vital registration data. We compared Hispanic ethnicity reported on the death certificate to Hispanic ethnicity derived from birthplace for the foreign-born and an algorithm that used first and last name and percentage of Hispanics in the county of residence for the US-born. We validated death certificate nativity by comparing data with that in linked Social Security Administration records. RESULTS: Ethnicity and birthplace information was concordant for foreign-born Hispanics, who have mortality rates that are 25% to 30% lower than those of non-Hispanic Whites. Death certificates likely underascertain deaths of US-born Hispanics, particularly at older ages, for persons with more education, and in census tracts with lower percentages of Hispanics. Conservative correction for under-ascertainment eliminates the Hispanic mortality advantage for US-born men. CONCLUSIONS: Hispanic ethnicity is accurately ascertained on the California death certificate for immigrants. Immigrant Hispanics have lower age-adjusted mortality rates than do non-Hispanic Whites. For US-born Hispanics, the mortality advantage compared with non-Hispanic Whites is smaller and may be explained by underreporting of Hispanic ethnicity on the death certificate.

Investigating the accuracy of ethnicity data in New Zealand hospital records: still room for improvement.

BACKGROUND: The accuracy of ethnicity information in the New Zealand hospital data was reported on in 1994. Data collected in the Barriers to Diabetes Care in the Waikato Study enables further evaluation of the accuracy of ethnicity information in hospital records. AIMS: One aim of public health policy is addressing health disparities between ethnic groups. Monitoring disparities depends on accurate outcome data, such as that from hospitals. It would be expected that this data would improve over time. This paper reports on the contemporary accuracy of ethnicity data in hospital records in the Waikato district. METHODS: Self-identified ethnicity data were gathered as part of the Barriers to Diabetes Care in the Waikato mail survey. Hospital record data were collected for those participants who had consented for access to their hospital records. RESULTS: Complete data was available for 3500 people with diabetes. Ethnicity in the hospital record was correct for one of the sometimes multiple, self-identified ethnicities for 97.7 (95CI 96.8-98.3)% of respondents. Ethnicity data were concordant for 71 (67-75)% of Maori and 99 (99-100)% of non-Maori. The non-Maori ethnic group was disaggregated into component groups: the hospital record agreed with self identified ethnicity for 89 (87-91)% of Europeans, 67 (55-78)% of Pacific groups, 70 (57-81)% of South Asian groups, 64 (48-77)% of Asian groups, and 41 (27-57)% of 'Other' ethnic groups. CONCLUSIONS: Hospital records continue to mis-record ethnicity when compared to a self-identified ethnicity. Mis-recording occurs for all ethnic groups, and is more pronounced at more specific levels of ethnic group. Researchers, clinicians, and policy makers must be cognisant of these continuing discrepancies when using hospital record data to describe ethnic variations in health status, service utilisation, or for policy planning activities.

Low back pain in older adults: are we utilizing healthcare resources wisely?

OBJECTIVES: 1) To examine recent change in prevalence and Medicare-associated charges for non-invasive/minimally invasive evaluation and treatment of nonspecific low back pain (LBP); and 2) to examine magnetic resonance imaging (MRI) utilization appropriateness in older adults with chronic low back pain (CLBP). DESIGN: Two cross-sectional surveys of 1) national (1991-2002) and Pennsylvania (2000-2002) Medicare data; and 2) patients aged >or= 65 years with CLBP. SETTING: Outpatient data. PARTICIPANTS: Patients aged >or= 65 years with LBP. MEASUREMENTS: Study 1: Outpatient national and Pennsylvania Part A Medicare data were examined for number of patients and charges for all patients, and for those with nonspecific LBP. Total number of visits and charges for imaging studies, physical therapy (PT), and spinal injections was also examined for Pennsylvania. Study 2: 111 older adults with CLBP were interviewed regarding presence of red flags necessitating imaging and history of having a lumbar MRI, neurogenic claudication (NC), and back surgery. RESULTS: Study 1: Between 1991 and 2002, there was a 42.5% increase in total Medicare patients, 131.7% increase in LBP patients, 310% increase in total charges, and 387.2% increase in LBP charges. In Pennsylvania (2000-2002), there was a 5.5% increase in LBP patients and 33.2% increase in charges (0.2% for PT, 59.4% for injections, 41.9% for MRI/CT, and 19.3% for X rays). Study 2: None of the 111 participants had red flags and 61% had undergone MRIs (29% with NC, 24% with failed back surgery syndrome). CONCLUSION: LBP documentation and diagnostic studies are increasing in Medicare beneficiaries, and evidence suggests that MRIs may often be ordered unnecessarily. Injection procedures appear to account for a significant proportion of LBP-associated costs. More studies are needed to examine the appropriateness with which imaging procedures and non-invasive/minimally invasive treatments are utilized, and their effect on patient outcomes.

Have DRG-based prospective payment systems influenced the number of secondary diagnoses in health care administrative data?

Diagnosis-related groups (DRGs) are secondary patient classification systems based on primary classified medical data, in which single events of care are grouped into larger, economically and medically consistent groups. The main primary classified medical data are diagnoses and surgery codes. In Sweden, the number of secondary diagnoses per case increased during the 1990s. In the early 1990s some county councils introduced DRG systems. The present study investigated whether the introduction of such systems had influenced the number of secondary diagnoses. The nation-wide Hospital Discharge Register from 1988 to 2000 was used for the analyses. All regional hospitals were included, giving a database of 5,355,000 discharges. The hospitals were divided into those that had introduced prospective payment systems during the study period and those that had not. Among all regional hospitals, there was an increase in the number of coded secondary diagnoses, but also in the number of secondary diagnoses per case. Hospitals with prospective payment systems had a larger increase, starting after the system was introduced. Regional hospitals without prospect payment systems had a more constant increase, starting later and coinciding with the introduction of their DRG-based management systems. It is concluded that introduction of DRG-based systems, irrespective of use, focuses on recording diagnoses and therefore increases the number of diagnoses. Other reasons may also have contributed to the increase. It was found that the changes in the speciality mix, during the study period, have impact on the increase of secondary diagnoses.

A data mining approach to characterizing medical code usage patterns.

This research describes a synthetic data mining approach to identifying diagnostic (ICD-9) and procedure (CPT) code usage patterns in two US. hospitals, with the goal of determining the adequacy and effectiveness of the current coding classification systems. We combine relative frequency measurements with measures of industry concentration borrowed from industrial economics in order to (1) ascertain the extent to which physicians utilize the available codes in classifying patients and (2) discover the factors that impinge on code usage. Our results partition the domain into areas for which the coding systems perform well and those areas for which the systems perform relatively poorly. The goal is to use this approach to understand how coding systems are used and to highlight areas for targeted improvement of the current coding

What if pediatric residents could bill for their outpatient services?

OBJECTIVE: We prospectively studied the potential of billing and coding practices of pediatric residents in outpatient clinics and extrapolated our results to assess the financial implications of billing inaccuracies. Using Medicare as a common measure of "currency," we also used the relative value unit (RVU) and ambulatory payment class methodologies as means of assessing the productivity and financial value of resident-staffed pediatric clinics. METHODS: Residents were asked to submit voluntarily shadow billing forms and documentation of outpatient clinic visits. Documentation of work was assessed by a blinded reviewer, and current procedure terminology evaluation and management codes were assigned. Comparisons between resident codes and calculated codes were made. Financial implications of physician productivity were calculated in terms of dollar amounts and RVUs. Resource intensity was measured using the ambulatory payment class methodology. RESULTS: A total of 344 charts were reviewed. Coding agreement for health maintenance visits was 86%, whereas agreement for acute care visits was 38%. Eighty-three percent of coding disagreement in the latter group was resulting from undercoding by residents. Errors accounted for a 4.79% difference in potential reimbursement for all visit types and a 19.10% difference for acute care visits. No significant differences in shadow billing discrepancies were found between different levels of training. Residents were predicted to generate $67 230, $87 593, and $96 072 in Medicare revenue in the outpatient clinic setting during each successive year of training. On average, residents generated 1.17 +/- 0.01 and 0.81 +/- 0.02 work RVUs for each health maintenance visit and office visit, respectively. Annual productivity from outpatient clinic settings was estimated at 548, 735, and 893 work RVUs in the postgraduate levels 1, 2, and 3, respectively. CONCLUSION: When pediatric residents are not trained adequately in proper coding practices, the potential for billing discrepancies is high and potential reimbursement differences may be substantial. Discussion of financial issues should be considered in curriculum development.

[The quality of the discharge reports from the internal medicine services of Castilla-La Mancha (a structural evaluation)]. / Calidad de los informes de alta de los Servicios de Medicina Interna de Castilla-La Mancha (valoración de la estructura).

UNLABELLED: The discharge report is one of the final outputs of the health care activity. We have tried to analyze several aspects related to its quality. For this purpose, we conducted a cross-sectional study analyzing 800 reports of patients admitted in the services of Internal Medicine at 6 hospitals of Castilla-La Mancha during the year 1991. We must stress the absence of discharge reports for death patients and the failure to record drug allergies (69.9%), medical history (10.4%) and time of evolution of the disease (16.9%), as well as treatment in 17 reports out of 781 and follow-up review after discharge in 12.8%. CONCLUSIONS: Discharge reports have a low scientific content and the production of this type of records is not a routine practice in the case of death patients.

Reducing unnecessary laboratory use with new test request form: example of tumour markers.

To limit the ordering of serum tumour marker tests that are clinically irrelevant, we designed a new request form. This is a matrix of boxes, rows being individual markers and columns body organs. The box at the intersection of line and column is colour-coded to indicate whether the test is appropriate or not. These ratings were allocated on the basis of published data and local consensus. This new form replaced the form in use at our hospital at the beginning of 1992, and resulted in a 25% decrease in the ordering of tumour markers. Adapting the design of the test request form is a low-cost intervention that combines both economic and clinical requirements in reducing the prescription of tests that are useless in a given clinical situation.