International Classification of Diseases, Tenth Revision Implementation: Is the Workforce Ready?

After many delays, the United States finally implemented the International Classification of Diseases, Tenth Revision, Clinical Modification/Procedural Coding System on October 1, 2015, bringing the United States into line with other industrialized nations, most of which had been using the International Classification of Diseases, Tenth Revision for many years. We outline the benefits and challenges to the preparatory activities of the International Classification of Diseases, Tenth Revision, Clinical Modification/Procedural Coding System implementation for the US health care industry. To ease the transition, the Centers for Medicare & Medicaid Services allowed health care facilities to submit test claims prior to the implementation date and delivered feedback on the acceptability of those claims. Early results indicated a relatively smooth transition, although some questions regarding the available data remain. Additional data, especially data concerning outcomes, are required.

[Medical information system (PMSI) does not adequately identify severe trauma]. / La codification PMSI identifie mal les traumatismes graves.

BACKGROUND: Resource allocation to hospitals is highly dependent on appropriate case coding. For trauma victims, the major diagnosis-coding category (DCC) is multiple trauma (DCC26), which triggers higher funding. We hypothesized that DCC26 has limited capacity for appropriate identification of severe trauma victims. METHODS: We studied Injury Severity Score (ISS), Trauma Related Injury Severity Score (TRISS) and in-hospital mortality using data recorded in three level 1 trauma centers over a 2-year period. Patients were divided into two groups: DCC26 and non-DCC26. For non-DCC26 patients, two subgroups were identified: patients with severe head trauma and patients with spinal trauma. Clinical endpoints were mortality, ISS>15 and TRISS, IGS II. Use of hospital resources was estimated using funding and expenditures associated with each patient. RESULTS: During the study period, 2570 trauma victims were included in the analysis. These patients were 39±18 years old, with median ISS=14, and observed mortality=10 %. Group DCC26 had 811 (31 %) patients, group non-DCC26 1855 (69 %) patients. DCC26 coding identified a more severely injured group of patients. However, in the group non-DCC26, there was a high proportion of severe trauma (ISS>15: 35 %; TRISS<0.95: 9 %). CONCLUSION: DCC26 is not an appropriate coding for severe trauma patients. For these patients, expenditures will include intensive care and rare and costly resources. We propose to take into account the TRISS score to improve trauma coding.

The latent nature of prolonged grief - A taxometric analysis: Results from a representative population sample.

Individuals suffering from prolonged grief disorder (PGD) show severe grief reactions after the death of a significant other, even beyond a period of grieving that is within a person's cultural and religious context. In addition to this core element, PGD can manifest in various ways. Symptoms may include persistent preoccupation, intense emotional pain, or impairment in important life domains. The symptoms, furthermore, have to be of culturally or religiously inappropriate extent or severity, taking into account different norms of grieving. PGD is discussed as a distinct diagnostic category in the revision of the International Classification of Diseases (ICD-11). Nosology of PGD has been highly debated surrounding the suggested inclusion in the DSM-5, which had been declined due to insufficient evidence. This paper addresses the latent nature of PGD. Using a short form of the Inventory of Complicated Grief-Revised (ICG-R), we applied three popular taxometric methods: MAXEIG, MAMBAC and L-Mode. Data stemmed from a subsample of N = 1445 bereaved individuals that participated in a large representative German population survey (N = 2520). The analysis strongly indicated a dimensional latent structure of PGD. Implications of the conceptualization of PGD on a continuum are discussed, regarding measurement, diagnosis, etiology and future research.

Adaptation and Validation of the Combined Comorbidity Score for ICD-10-CM.

BACKGROUND: The combined comorbidity score, which merges the Charlson and Elixhauser comorbidity indices, uses the ninth revision of the International Classification of Diseases, Clinical Modification (ICD-9-CM). In October 2015, the United States adopted the 10th revision (ICD-10-CM). OBJECTIVE: The objective of this study is to examine different coding algorithms for the ICD-10-CM combined comorbidity score and compare their performance to the original ICD-9-CM score. METHODS: Four ICD-10-CM coding algorithms were defined: 2 using General Equivalence Mappings (GEMs), one based on ICD-10-CA (Canadian modification) codes for Charlson and Elixhauser measures, and one including codes from all 3 algorithms. We used claims data from the Clinfomatics Data Mart to identify 2 cohorts. The ICD-10-CM cohort comprised patients who had a hospitalization between January 1, 2016 and March 1, 2016. The ICD-9-CM cohort comprised patients who had a hospitalization between January 1, 2015 and March 1, 2015. We used logistic regression models to predict 30-day hospital readmission for the original score in the ICD-9-CM cohort and for each ICD-10-CM algorithm in the ICD-10-CM cohort. RESULTS: Distributions of each version of the score were similar. The algorithm based on ICD-10-CA codes [c-statistic, 0.646; 95% confidence interval (CI), 0.640-0.653] had the most similar discrimination for readmission to the ICD-9-CM version (c, 0.646; 95% CI, 0.639-0.653), but combining all identified ICD-10-CM codes had the highest c-statistic (c, 0.651; 95% CI, 0.644-0.657). CONCLUSIONS: We propose an ICD-10-CM version of the combined comorbidity score that includes codes identified by ICD-10-CA and GEMs. Compared with the original score, it has similar performance in predicting readmission in a population of United States commercially insured individuals.

Bayesian analysis of genetic association across tree-structured routine healthcare data in the UK Biobank.

Genetic discovery from the multitude of phenotypes extractable from routine healthcare data can transform understanding of the human phenome and accelerate progress toward precision medicine. However, a critical question when analyzing high-dimensional and heterogeneous data is how best to interrogate increasingly specific subphenotypes while retaining statistical power to detect genetic associations. Here we develop and employ a new Bayesian analysis framework that exploits the hierarchical structure of diagnosis classifications to analyze genetic variants against UK Biobank disease phenotypes derived from self-reporting and hospital episode statistics. Our method displays a more than 20% increase in power to detect genetic effects over other approaches and identifies new associations between classical human leukocyte antigen (HLA) alleles and common immune-mediated diseases (IMDs). By applying the approach to genetic risk scores (GRSs), we show the extent of genetic sharing among IMDs and expose differences in disease perception or diagnosis with potential clinical implications.

[The draft of the ICD-11 chapter on mental and behavioral disorders: an update for clinicians]. / Il draft del capitolo sui disturbi mentali dell'ICD-11: un aggiornamento per il clinico.

The ICD-11 chapter on mental and behavioral disorders is currently under development. A simplified version of the diagnostic guidelines for schizophrenia and other primary psychotic disorders, mood disorders, anxiety disorders, disorders specifically associated with stress, and feeding and eating disorders has been made available for use in the field studies. For all the other sections of the classification, a brief general definition and sometimes a description of some of the included disorders can be found on the ICD-11 beta platform. In the present article, we provide some information on the content of the various sections of the classification on the basis of the available documents, with the warning that some of the aspects may still be subject to revision.

Use of Emergency Department Data to Monitor and Respond to an Increase in Opioid Overdoses in New Hampshire, 2011-2015.

OBJECTIVES: Opioid-related overdoses and deaths in New Hampshire have increased substantially in recent years, similar to increases observed across the United States. We queried emergency department (ED) data in New Hampshire to monitor opioid-related ED encounters as part of the public health response to this health problem. METHODS: We obtained data on opioid-related ED encounters for the period January 1, 2011, through December 31, 2015, from New Hampshire's syndromic surveillance ED data system by querying for (1) chief complaint text related to the words "fentanyl," "heroin," "opiate," and "opioid" and (2) opioid-related International Classification of Diseases ( ICD) codes. We then analyzed the data to calculate frequencies of opioid-related ED encounters by age, sex, residence, chief complaint text values, and ICD codes. RESULTS: Opioid-related ED encounters increased by 70% during the study period, from 3300 in 2011 to 5603 in 2015; the largest increases occurred in adults aged 18-29 and in males. Of 20 994 total opioid-related ED visits, we identified 18 554 (88%) using ICD code alone, 690 (3%) using chief complaint text alone, and 1750 (8%) using both chief complaint text and ICD code. For those encounters identified by ICD code only, the corresponding chief complaint text included varied and nonspecific words, with the most common being "pain" (n = 3335, 18%), "overdose" (n = 1555, 8%), "suicidal" (n = 816, 4%), "drug" (n = 803, 4%), and "detox" (n = 750, 4%). Heroin-specific encounters increased by 827%, from 4% of opioid-related encounters in 2011 to 24% of encounters in 2015. CONCLUSIONS: Opioid-related ED encounters in New Hampshire increased substantially from 2011 to 2015. Data from New Hampshire's ED syndromic surveillance system provided timely situational awareness to public health partners to support the overall response to the opioid epidemic.

Primary care physicians' use of the proposed classification of common mental disorders for ICD-11.

Background: The World Health Organization is revising the classification of common mental disorders in primary care for ICD-11. Major changes from the ICD-10 primary care version have been proposed for: (i) mood and anxiety disorders; and (ii) presentations of multiple somatic symptoms (bodily stress syndrome). This three-part field study explored the implementation of the revised classification by primary care physicians (PCPs) in five countries. Methods: Participating PCPs in Brazil, China, Mexico, Pakistan and Spain were asked to use the revised classification, first in patients that they suspected might be psychologically distressed (Part 1), and second in patients with multiple somatic symptoms causing distress or disability not wholly attributable to a known physical pathology, or with high levels of health anxiety (Part 2). Patients referred to Part 1 or Part 2 underwent a structured diagnostic interview. Part 3 consisted of feedback from PCPs regarding the classification. Results: In Part 1, anxious depression was the most common disorder among referred patients. PCPs assigned the highest severity ratings to anxious depression, and the next highest to current depression; current anxiety was rated as least severe. Considerable overlap was found between bodily stress syndrome (BSS) and health anxiety (HA). The psychiatric interview recorded higher rates of mood and anxiety disorders diagnoses among patients with BSS than did PCPs. PCPs' satisfaction with the revised classification was high. Conclusions: Results generally supported the inclusion of the new categories of anxious depression, BSS and HA for ICD-11 PHC and suggested that PCPs could implement these categories satisfactorily.

Diagnosing delirium in very elderly intensive care patients.

OBJECTIVE: To determine the incidence of delirium in elderly intensive care patients and to compare incidence using two retrospective chart-based diagnostic methods and a hospital reporting measure (ICD-10). DESIGN: Retrospective study. SETTING: An ICU in a large metropolitan private hospital in Melbourne, Australia. PATIENTS: English-speaking participants (n=348) 80+ years, admitted to ICU for >24 hours. MEASUREMENTS AND MAIN RESULTS: Medical files of ICU patients admitted October 2009-October 2012 were retrospectively assessed for delirium using the Inouye chart review method, DSM-IV diagnostic criteria and ICD-10 coding data. General patient characteristics, first onset of delirium symptoms, source of delirium information, administration of delirium medication, hospital and ICU length of stay, 90 day mortality were documented. Delirium was found in 11-29% of patients, the highest incidence identified by chart review. Patients diagnosed with delirium had higher 90 day mortality, and those meeting criteria for all three methods had longer hospital and ICU length of stay. CONCLUSIONS: ICU delirium in the elderly is often under-reported and strategies are needed to improve staff education and diagnosis.

Applying the international classification of diseases to perinatal mortality data, South Africa

Objective:To examine the feasibility of applying the International Classification of Diseases-perinatal mortality (ICD-PM) coding to an existing data set in the classification of perinatal deaths.Methods One author, a researcher with a non-clinical public health background, applied the ICD-PM coding system to South Africa's national perinatal mortality audit system, the Perinatal Problem Identification Program. The database for this study included all perinatal deaths (n=26 810), defined as either stillbirths (of birth weight >1000 g and after 28 weeks of gestation) or early neonatal deaths (age 0­7 days), that occurred between 1 October 2013 and 31 December 2016. A clinical obstetrician verified the coding. Findings The South African classification system does not include the timing of death; however, under the ICD-PM system, deaths could be classified as antepartum (n=15 619; 58.2%), intrapartum (n=3725; 14.0%) or neonatal (n=7466; 27.8%). Further, the South African classification system linked a maternal condition to only 40.3% (10 802/26 810) of all perinatal deaths; this proportion increased to 68.9% (18 467/26 810) under the ICD-PM system. Conclusion The main benefit of using the clinically relevant and user-friendly ICD-PM system was an enhanced understanding of the data, in terms of both timing of death and maternal conditions. We have also demonstrated that it is feasible to convert an existing perinatal mortality classification system to one which is globally comparable and can inform policy-makers internationally

Field testing of the ICHD-3ß and expert opinion criteria for chronic migraine.

BACKGROUND: Chronic headache (CrH) occurs commonly in the population, and chronic migraine (CM) accounts for much of the CrH. Diagnostic criteria for CM remain controversial, and this could lead to undertreatment of CM. The purpose of this study was to analyze the clinical profiles of CM and to field test the International Classification of Headache Disorders-3ß criteria (ICHD-3ß) and Expert Opinion criteria (EO) for CM application. METHODS: We retrospectively reviewed the medical records of CrH patients in our headache clinic during the period. Eligible patients were selected from CrH population based on Silberstein and Lipton criteria (S-L) for CM, and meanwhile fulfilled with migraine days at least 8 days/month. Then we evaluated the characteristics of clinic profiles and outcomes between patients diagnosed CM using ICHD-3ß and EO criteria. Field tested the CM criteria Of ICHD-3ß and EO. RESULTS: In a total of 710 CrH patients , 261 (36.8 %) were recruited with CM based on both S-L criteria and fulfilled at least 8 migraine days/month. Be understandable, all the 261 patients met the EO criteria, and only 185 (70.9 %) met ICHD-3ß for CM. For the 76 patients who met EO but not ICHD-3ß, 70 had atypical migraine attacks (probable migraine, PM), and another 6 had typical migraine attacks but less than a total history of 5 attacks. Although 173 (66.3 %) were concurrent with medication overuse, just one patient overused triptans and none used ergot agents. Clinical features were not significantly different between the ICHD-3ß and EO criteria groups (P > 0.05), and neither were outcomes of prophylaxis (P = 0.966). Total migraine prophylaxis effectiveness was 73 %. CONCLUSION: Migraine-specific analgesics are rarely used in China, permitting patients with PM to avail themselves of "migraine days" is a reasonable accommodation for this difficult condition. In our hands, use of the new EO criteria for diagnosis of CM increases the sensitivity and maintains the specificity of decision making, and therefore should be adopted in CM management practice.

Military Occupations Most Affected by Head/Sensory Injuries and the Potential Job Impact of Those Injuries.

OBJECTIVE: Identifying Department of Defense (DoD) occupations affected by injuries to the head and sensory systems. METHODS: We explored the Defense Medical Epidemiology Database to identify occupations with the highest incidence of injured personnel, then ranked how frequently they occurred in a top 10 list for each of four injury categories (head/brain, visual, auditory, vestibular) encompassing 25 injury codes. Across all four categories, the most affected occupations were identified, among which we chose three Army combat-related military occupational specialties (MOSs) for detailed study. We identified skills needed to perform these MOSs and explored whether MOS-critical deficits could be expected following the injuries. RESULTS: Some DoD occupations are more likely to suffer from these injuries, including Infantry, Combat Operations Control, Artillery/Gunnery, Motor Vehicle Operator, Combat Engineering, and Armor/Amphibious. Within these DoD occupations, we explored three Army combatant MOSs: Infantry (11B), Cavalry Scout (19D), and Artillery (13B), confirming that these jobs are likely to be disrupted by injuries within the four categories. CONCLUSIONS: Head and sensory injuries disproportionately affect certain military occupations. Relatively few injuries disrupt combat-related abilities that are job critical (e.g., firearms operation) and job specific (e.g., Artillery gunnery problems); these should be the focus of efforts to improve rehabilitation and RTD outcomes.

The reporting and diagnosis of uterine fibroids in the UK: an observational study.

BACKGROUND: Uterine fibroids (UFs) are the most common benign tumour in women, and many undergo hysterectomy or uterus-preserving procedures (UPPs) to manage their symptoms. We aimed to validate the recording of UFs in a primary care database, The Health Improvement Network (THIN), and to determine the incidence of UFs in the UK. METHODS: In this observational study, women in THIN aged 15-54 years between January 2000 and December 2009 with no previous record of UFs, hysterectomy or UPPs were identified. Individuals were followed up until there was a Read code indicating UFs, they reached 55 years of age or died, or the study ended. Among those without a UF code, women were identified with a code for hysterectomy, UPPs or heavy menstrual bleeding (HMB). Anonymized patient profiles from each category were randomly selected and reviewed. Subsequently, primary care physicians were asked to complete questionnaires to verify the diagnosis for a randomly selected subgroup. RESULTS: In total, 737,638 women were identified who met the initial inclusion criteria. The numbers of women with a code for UFs, hysterectomy, UPPs and HMB were 9380, 11,002, 3220 and 60,915, respectively; the proportions of confirmed cases of UFs were 88.8, 29.7, 57.7 and 15.9 %. The estimated number of women with UFs was 23,140 (64.0 % without a recorded UF diagnosis). The overall incidence of UFs was 5.8 per 1000 woman-years. CONCLUSIONS: UFs were confirmed in a high proportion of women with UF Read codes. However, almost two-thirds of cases were identified among women with a code for hysterectomy, UPPs or HMB. These results show that UFs are under-recorded in UK primary care, and suggest that primary care physicians tend to code the symptoms of UFs more often than the diagnosis.

An integrated national mortality surveillance system for death registration and mortality surveillance, China.

In China, sample-based mortality surveillance systems, such as the Chinese Center for Disease Control and Prevention's disease surveillance points system and the Ministry of Health's vital registration system, have been used for decades to provide nationally representative data on health status for health-care decision-making and performance evaluation. However, neither system provided representative mortality and cause-of-death data at the provincial level to inform regional health service needs and policy priorities. Moreover, the systems overlapped to a considerable extent, thereby entailing a duplication of effort. In 2013, the Chinese Government combined these two systems into an integrated national mortality surveillance system to provide a provincially representative picture of total and cause-specific mortality and to accelerate the development of a comprehensive vital registration and mortality surveillance system for the whole country. This new system increased the surveillance population from 6 to 24% of the Chinese population. The number of surveillance points, each of which covered a district or county, increased from 161 to 605. To ensure representativeness at the provincial level, the 605 surveillance points were selected to cover China's 31 provinces using an iterative method involving multistage stratification that took into account the sociodemographic characteristics of the population. This paper describes the development and operation of the new national mortality surveillance system, which is expected to yield representative provincial estimates of mortality in China for the first time.

En Chine, des systèmes de surveillance de la mortalité fondés sur des échantillons (comme le système à points de surveillance des maladies du Centre chinois pour le contrôle et la prévention des maladies et le système d'enregistrement des données d'état civil du ministère de la Santé) sont utilisés depuis plusieurs dizaines d'années pour obtenir des données représentatives à l'échelle nationale de la situation sanitaire, en vue d'éclairer les processus décisionnels en matière de santé et d'évaluer les résultats. Or, aucun de ces systèmes traditionnellement utilisés ne proposait de données représentatives sur la mortalité et les causes de décès à l'échelle provinciale, pourtant nécessaires pour correctement définir les priorités et les besoins régionaux en matière de politiques de santé. Par ailleurs, ces systèmes étaient largement redondants entre eux, ce qui impliquait donc une duplication inutile des efforts. En 2013, le gouvernement chinois a fusionné ces deux systèmes dans un système national intégré de surveillance de la mortalité afin d'obtenir une image représentative à l'échelle provinciale de la mortalité totale et de la mortalité par cause et d'accélérer la création d'un système exhaustif d'enregistrement des données d'état civil et de surveillance de la mortalité pour tout le pays. Ce nouveau système a permis d'augmenter la couverture de la surveillance (de 6% de la population chinoise couverte auparavant à 24%). Le nombre de points de surveillance (chacun couvrant un district ou un comté) est passé de 161 à 605. Pour garantir une bonne représentativité à l'échelle provinciale, les 605 points de surveillance ont été sélectionnés de manière à couvrir les 31 provinces chinoises à l'aide d'une méthode itérative impliquant une stratification à plusieurs degrés qui a tenu compte des caractéristiques sociodémographiques de la population. Cet article décrit l'élaboration et le fonctionnement de ce nouveau système national de surveillance de la mortalité, qui devrait permettre d'obtenir pour la première fois des estimations représentatives à l'échelle provinciale de la mortalité en Chine.

En China, los sistemas de vigilancia de la mortalidad basados en muestras, tales como el sistema de puntos de vigilancia de las enfermedades del Centro de Prevención y Control de Enfermedades de China y el sistema de registro civil del Ministerio de Salud, se han utilizado durante décadas para proporcionar datos nacionalmente representativos del estado de salud para tomar decisiones médicas y evaluaciones de rendimiento. Sin embargo, ningún sistema ofrecía datos representativos en cuanto a defunciones y las causas de las defunciones a un nivel provincial con el objetivo de informar de las necesidades de servicios sanitarios regionales y las prioridades de la política. Asimismo, los sistemas se solapaban hasta un punto considerable, lo que suponía una duplicación de los esfuerzos. En 2013, el gobierno chino combinó estos dos sistemas en un sistema nacional integrado de vigilancia de la mortalidad para proporcionar una imagen provincialmente representativa de la mortalidad total y de la mortalidad por causas específicas y para acelerar el desarrollo de un registro civil completo y un sistema de vigilancia de la mortalidad para todo el país. Este nuevo sistema aumentó la población de vigilancia de un 6 a un 24% de la población china. El número de puntos de vigilancia, donde cada uno cubría un distrito o condado, subió de 161 a 605. Con el objetivo de garantizar una representación a nivel provincial, los 605 puntos de vigilancia se seleccionaron para cubrir las 31 provincias de China mediante la utilización de un método iterativo que consistía en una estratificación de etapas múltiples que tenía en cuenta las características sociodemográficas de la población. Este artículo describe el desarrollo y funcionamiento del nuevo sistema nacional de vigilancia de la mortalidad, el cual se espera que aumente las estimaciones provinciales representativas de mortalidad en China por primera vez.

Coding of Neuroinfectious Diseases.

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.

A critical view of transgender health care in Germany: Psychopathologizing gender identity - Symptom of 'disordered' psychiatric/psychological diagnostics?

After explaining the essential trans* terminology, I offer a short historical overview of the way health care has dealt with the subject of gender, trans* and health in different times. In the third section, I compare the world's most important diagnostic manuals, namely the International statistical classification of diseases and related health problems (ICD) and the Diagnostic and statistical manual of mental disorders (DSM), i.e. their criteria for 'gender identity disorders' (ICD-10) and 'gender dysphoria' (DSM-5). The fourth section branch out the factors which influence every diagnostic conception - of no matter whom - in the health care system. The last section discusses the implications resulting from this diagnostic dilemma for the health situation of gender nonconforming people.