Is Administratively Coded Comorbidity and Complication Data in Total Joint Arthroplasty Valid?
ABSTRACT BACKGROUND: Administrative claims data are increasingly being used in public reporting of provider performance and health services research. However, the concordance between administrative claims data and the clinical record in lower extremity total joint arthroplasty (TJA) is unknown. QUESTIONS/PURPOSES: We evaluated the concordance between administrative claims and the clinical record for 13 commonly reported comorbidities and complications in patients undergoing TJA. METHODS: We compared 13 administratively coded comorbidities and complications derived from hospital billing records with clinical documentation from a consecutive series of 1350 primary and revision TJAs performed at three high-volume institutions during 2009. RESULTS: Concordance between administrative claims and the clinical record varied across comorbidities and complications. Concordance between diabetes and postoperative myocardial infarction was reflected by a kappa value > 0.80; chronic lung disease, coronary artery disease, and postoperative venous thromboembolic events by kappa values between 0.60 and 0.79; and for congestive heart failure, obesity, prior myocardial infarction, peripheral arterial disease, bleeding complications, history of venous thromboembolism, prosthetic-related complications, and postoperative renal failure by kappa values between 0.40 and 0.59. All comorbidities and complications had a high degree of specificity (> 92%) but lower sensitivity (29%-100%). CONCLUSIONS: The data suggest administratively coded comorbidities and complications correlate reasonably well with the clinical record. However, the specificity of administrative claims is much higher than the sensitivity, indicating that comorbidities and complications coded in the administrative record were accurate but often incomplete. LEVEL OF EVIDENCE: Level II, prognostic study. See the Guidelines for Authors for a complete description of levels of evidence.
SourceAvailable from: Michele R D'Apuzzo[Show abstract] [Hide abstract]
ABSTRACT: The importance of morbid obesity as a risk factor for complications after total knee arthroplasty (TKA) continues to be debated. Obesity is rarely an isolated diagnosis and tends to cluster with other comorbidities that may independently lead to increased risk and confound outcomes. It is unknown whether morbid obesity independently affects postoperative complications and resource use after TKA. The purpose of this study was to determine whether morbid obesity is an independent risk factor for inpatient postoperative complications, mortality, and increased resource use in patients undergoing primary TKA. The Healthcare Cost and Utilization Project Nationwide Inpatient Sample (NIS) database was used to identify patients undergoing primary TKA from October 2005 to December 2008. Morbid obesity (body mass index ≥ 40 kg/m(2)) was determined using International Classification of Diseases, 9(th) Revision, Clinical Modification codes. In-hospital postoperative complications, mortality, costs, and disposition for morbidly obese patients were compared with nonobese patients. To control for potential confounders and comorbid conditions, each morbidly obese patient was matched to a nonobese patient using age, sex, and all 28 comorbid-defined elements in the NIS database based on the Elixhauser Comorbidity Index. Of 1,777,068 primary TKAs, 98,410 (5.5%) patients were categorized as morbidly obese. Of these, 90,045 patients (91%) were able to be matched one-to-one to a nonobese patient for the adjusted analysis. Morbidly obese patients had a higher risk of postoperative in-hospital infection (0.24% versus 0.17%; odds ratio [OR], 1.3; 95% confidence interval [CI], 1.1-1.7; p = 0.001), wound dehiscence (0.11% versus 0.08%; OR, 1.3; 95% CI, 1.0-1.7; p = 0.28), and genitourinary-related complications (0.60% versus 0.44%; OR, 1.3; 95% CI, 1.1-1.5; p < 0.001). There was no increase in the prevalence of cardiovascular or thromboembolic-related complications. Morbidly obese patients were at higher risk of in-hospital death after primary TKA compared with nonobese patients (0.08% versus 0.02%; OR, 3.2; 95% CI, 2.0-5.2; p < 0.001). Total hospital costs (USD 15,174 versus USD 14,715, p < 0.001), length of stay (3.6 days versus 3.5 days, p < 0.001), and rate of discharge to a facility (40% versus 30%, p < 0.001) were all higher in morbidly obese patients. Morbid obesity appears to be independently associated with a higher risk for a small number of select in-hospital postoperative complications and mortality after matching for comorbid medical conditions linked to obesity. However, the independent impact of morbid obesity appears to be fairly modest, and morbid obesity did not appear to be an independent risk factor for many systemic complications. Continued research is necessary to identify the influence of associated comorbidities on early postoperative complications in morbidly obese patients after TKA. Level II, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.Clinical Orthopaedics and Related Research 05/2014; 473(1). DOI:10.1007/s11999-014-3668-9 · 2.88 Impact Factor
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ABSTRACT: : Study Design. Cross-sectionalObjective. To objectively evaluate the ability of International Classification of Diseases, Ninth Revision (ICD-9) codes, which are used as the foundation for administratively coded national databases, to identify preoperative anemia in spinal fusion patients.Summary of Background Data. National database research in spine surgery continues to rise. However, the validity of studies based on administratively coded data, such as the Nationwide Inpatient Sample (NIS), are dependent on the accuracy of ICD-9 coding. Such coding has previously been found to have poor sensitivity for conditions such as obesity and infection.Methods. A cross-sectional study was performed at an academic medical center. Hospital-reported anemia ICD-9 codes (those used for administratively coded databases) were directly compared to the chart-documented preoperative hematocrits (true laboratory values). A patient was deemed to have preoperative anemia if the preoperative hematocrit was less than the lower end of the normal range (36.0% for females and 41.0% for males).Results. The study included 260 patients. Of these, 37 patients (14.2%) were anemic; however, only 10 patients (3.8%) received an "anemia" ICD-9 code. Of those coded as anemic, 7 of these 10 patients were anemic by definition, while 3 were not, and thus were miscoded. This equates to an ICD-9 code sensitivity of 0.19, with a specificity of 0.99, and positive and negative predictive values of 0.70 and 0.88, respectively.Conclusions. The current study uses preoperative anemia to demonstrate the potential inaccuracies of ICD-9 coding. These results have implications for publications using databases that are compiled from ICD-9 coding data. Furthermore, the findings of the current investigation raise concerns regarding the accuracy of additional comorbidities. Although administrative databases are powerful resources that provide large sample sizes, it is crucial that we further consider the quality of the data source relative to its intended purpose.Spine 09/2014; DOI:10.1097/BRS.0000000000000598 · 2.45 Impact Factor
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ABSTRACT: Although the association between chronic, high-dose corticosteroid use and osteonecrosis is well known, the incidence of osteonecrosis following short-term, low-dose steroid taper packs has never been reported across a large population. The goal of this study was to report the incidence and risk of osteonecrosis after methylprednisolone taper pack (MTP) prescriptions in a multicenter electronic medical records database. A commercially available software platform was used to evaluate the records of 24,533,880 patients to determine the incidence of osteonecrosis in patients who had received single or multiple MTP over a 12-year period. This was compared with the incidence of osteonecrosis in patients who had never been prescribed an MTP. Patients with a history of osteonecrosis or prior corticosteroid use were excluded from the study. A total of 98,390 patients were identified who had received a single MTP. One hundred thirty (0.132%; 95% confidence interval [CI], 0.176%-0.283%) of these patients were subsequently diagnosed with osteonecrosis. The incidence of osteonecrosis in patients who had been prescribed 2 or more MTPs was 0.230% (95% CI, 0.176%-0.283%). Compared with the 0.083% incidence of osteonecrosis in the control group that had never been prescribed an MTP, the relative risk of osteonecrosis after the prescription of a single MTP or multiple MTPs was 1.591 and 2.763, respectively, with a statistically significant difference between cohorts (P<.001). Short-term, low-dose oral corticosteroid administration may be associated with a low but statistically significant increased incidence of osteonecrosis when compared with patients who have never been prescribed a steroid product.Orthopedics 07/2014; 37(7):e631-e636. DOI:10.3928/01477447-20140626-54 · 0.98 Impact Factor