Assessing validity of ICD-9-CM and ICD-10 administrative data in recording clinical conditions in a unique dually coded database.The World Health Organization adopted the first version of the International Classification of Diseases (ICD ICD International Classification of Diseases (of the World Health Organization); intrauterine contraceptive device.
abbr. ) in 1900 to internationally monitor and compare mortality statistics and causes of death. Since then, the classification has been revised periodically to accommodate new knowledge of disease and health. The sixth revision, published in 1949, was more radical than the previous five revisions because this edition made it possible to record information from patient charts to compile morbidity statistics. Subsequent revisions were made in 1958 (7th Edition), in 1968 (8th Edition), and in 1979 (9th Edition). The United States United States, officially United States of America, republic (2005 est. pop. 295,734,000), 3,539,227 sq mi (9,166,598 sq km), North America. The United States is the world's third largest country in population and the fourth largest country in area. modified ICD-9 by specifying many categories and extending coding rubrics to describe the clinical picture in more detail. These modifications resulted in the publication of ICD-9 Clinical Modification (ICD-9-CM) in 1979 for coding diagnoses in patient charts (Commission on Professional and Hospital Activities 1986). The latest version, ICD-10, was introduced in 1992 (World Health Organization 1992).
The major differences between the ICD-10 and ICD-9-CM coding systems are: (1) the tabular list in ICD-10 has 21 categories of disease compared with 19 categories in ICD-9-CM and the category of diseases of the nervous system and sense organs in ICD-9-CM is divided into three categories in ICD-10, including diseases of the nervous system, diseases of the eye and adnexa adnexa /ad·nexa/ (ad-nek´sah) [L., pl.] appendages or accessory structures of an organ, as the appendages of the eye (a. o´culi), including the eyelids and lacrimal apparatus, or of the uterus (a. , and diseases of the ear and mastoid process mastoid process
1. A conical protuberance of the posterior portion of the temporal bone that is situated behind the ear and serves as a site of muscle attachment. Also called mastoid bone.
2. ; and (2) the codes in ICD-10 are alphanumeric while codes in ICD-9-CM are numeric. Each code in ICD-10 starts with a letter (i.e., A-Z), followed by two numeric digits, a decimal, and a digit (e.g., acute bronchiolitis Bronchiolitis Definition
Bronchiolitis is an acute viral infection of the small air passages of the lungs called the bronchioles.
Bronchiolitis is extremely common. due to respiratory syncytial virus respiratory syncytial virus (sĭnsĭsh`əl): see cold, common. is J21.0). In contrast, codes in ICD-9-CM begin with three digit numbers (i.e., 001-999), that are followed by a decimal and up to two digits (e.g., acute bronchiolitis due to respiratory syncytial virus is 466.11).
Canada, Australia, Germany, and other countries have enhanced ICD-10 by adding more specific codes and released country-specific ICD-10 versions, such as ICD-10-Canada (ICD-10-CA; Canadian Institute for Health Information The Canadian Institute for Health Information (CIHI) is an independent, not-for-profit organization in Canada, primarily funded by the provincial and federal governments of Canada. 2003). However, ICD-10-CA has maintained its comparability with ICD-10. The basic ICD-10 structure, scope, content, and definition of existing codes are not altered in ICD-10-CA. This means that none of the ICD-10 codes are relocated or deleted. ICD-10-CA mainly extends code character levels, from third and fourth levels of ICD-10 to fourth, fifth, or sixth character levels (e.g., from I15.0 for renovascular hypertension Renovascular Hypertension Definition
Renovascular hypertension is a secondary form of high blood pressure caused by a narrowing of the renal artery.
Primary hypertension, or high blood pressure, affects millions of Americans. to I15.00 for benign renovascular hypertension and 115.01 for malignant renovascular hypertension). A few additions of third- and fourth-level codes were also included in ICD-10-CA in a manner consistent with the existing classification. All of these additional codes are indicated with red maple red maple
see acerrubrum. leaf symbols in ICD-10-CA coding manuals.
To continuously study the health care system and investigate or monitor population health status with ICD-10 data, it is imperative to assess errors that could occur in the process of creating administrative data due to the introduction of the new coding system Noun 1. coding system - a system of signals used to represent letters or numbers in transmitting messages
code - a coding system used for transmitting messages requiring brevity or secrecy , ICD-10. We conducted this study to evaluate the validity of ICD-10 administrative hospital discharge data and to determine whether there were improvements in the validity compared with the validity of ICD-9-CM data. To achieve this aim, we reviewed randomly selected charts coded using ICD-10 at four Canadian teaching hospitals, determined the presence or absence of recorded conditions, and then separately recoded the same charts using ICD-9-CM. Then we assessed the agreement between originally coded ICD-10 administrative and chart review data, and the recoded ICD-9-CM administrative data and chart review data for recording the same conditions. This permitted us to compare the accuracy of ICD-10 data relative to the chart review data, with the accuracy of ICD-9-CM data relative to the chart review data for these conditions.
Original ICD-10-CA Hospital Discharge Abstract Administrative Data
At each of the four adult teaching hospitals in Alberta, Canada, professionally trained health record coders read through the patients' medical charts to assign ICD-10-CA diagnoses that appropriately described the patient's hospitalization. Each discharge record contained a unique identification number for each admission, a patient chart number, and up to 16 diagnoses. Alberta hospital discharge records have been coded with ICD-10-CA since April 1, 2002. To avoid quality issues in coding during the transition period between ICD-9-CM and ICD-10-CA, we obtained all records for patients with ages [greater than or equal to] 18 and discharged from January 1, 2003 through June 30, 2003 (i.e., 9 months after the implementation of ICD-10-CA) from the four study hospitals. After stratifying records by hospital, and assigning a random number to each record, we sorted them by ascendance as·cen·dance also as·cen·dence
Noun 1. ascendance - the state that exists when one person or group has power over another; "her apparent dominance of her husband was really her attempt to make him pay of the random number and assigned a sequence number to each record within hospital. With the aim of having a final sample size of at least 1,000 records from each hospital, we located charts sequentially using a combination of patient chart number and admission identification number unique to admission at each hospital. We ended up reviewing 4,008 charts and did not locate 26 charts (i.e., a 99 percent success rate in locating charts).
Recoded ICD-9-CM Hospital Discharge Abstract Data (Simulating Real- World Coding)
Before April 1, 2002, discharge data were coded with ICD-9-CM and therefore, in our sampling period of January 1 to June 30, 2003, ICD-9-CM data were not available in Alberta. To create a new ICD-9-CM database, we attempted to simulate hospital coders' coding in ICD-9-CM (i.e., "real-world coding"). Four coders who had ICD-9-CM coding experience at these hospitals recoded the 4,008 charts following the ICD-9-CM coding guidelines used at the four hospitals at the average speed of coding staff, spending about 15-20 minutes per chart. These coders were blinded to the ICD-10-CA codes assigned to each record.
Defining Clinical Conditions in ICD-9-CM and ICD-10-CA Data
Through multiple steps, we developed ICD-10 coding algorithms and enhanced the Deyo and Elixhauser ICD-9-CM coding algorithms for adaptation of the Charlson and Elixhauser clinical conditions in ICD-9-CM and ICD-10 administrative data. Our multistep process for doing this is described in detail in a previously published paper (Quan et al. 2005). The ICD-10 coding algorithms used for this study did not contain country-specific ICD-10 codes. When the coding algorithms were used to define 32 conditions in ICD-9-CM and ICD-10-CA databases, respectively, using up to 16 diagnosis coding fields, we utilized the SAS (1) (SAS Institute Inc., Cary, NC, www.sas.com) A software company that specializes in data warehousing and decision support software based on the SAS System. Founded in 1976, SAS is one of the world's largest privately held software companies. See SAS System. functional command of "substr" to truncate To cut off leading or trailing digits or characters from an item of data without regard to the accuracy of the remaining characters. Truncation occurs when data are converted into a new record with smaller field lengths than the original. the length of ICD-10 codes in the ICD-10-CA database. Therefore we defined the 32 conditions using the ICD-10 codes rather than ICD-10-CA codes and avoided influence of Canadian extended digits or additional codes on these conditions. This methodological approach is intentional, to increase the international relevance of our findings. We chose the Charlson index (Charlson et al. 1987) and Elixhauser measures (Elixhauser et al. 1998) because they have been widely used by health researchers to measure burden of disease or case mix with administrative data (Southern, Quan, and Ghali 2004; Sundararajan et al. 2004; Needham et al. 2005).
Chart Review Data
Two reviewers who have nursing backgrounds and health records coding training, as well as extensive chart review experience, reviewed the randomly selected charts to determine the presence or absence of 32 conditions. The chart reviewers followed the definitions described by Charlson et al. (1987) to determine the presence or absence of the 14 conditions that constitute the Charlson index. To determine the presence or absence of the remaining 18 Elixhauser clinical conditions in the charts, we developed explicit definitions by describing all of the ICD-10 codes that were used to define the 18 conditions, with the clinical terms used in the ICD-10 manuals.
Two reviewers underwent training in data extraction Data extraction is the act or process of retrieving (binary) data out of (usually unstructured or badly structured) data sources for further data processing or data storage (data migration). with the lead investigator (H. Q.). In the training session, the definition of study variables was discussed and eight charts were reviewed. Any discrepancies between the two reviewers in reviewing these eight charts were discussed and resolved by consensus involving a third party. The agreement between the two reviewers was then evaluated. Both of the reviewers independently extracted clinical conditions from 70 charts using a predesigned standard form from one of the teaching hospitals. Of the 32 conditions extracted from these 70 charts, 17 conditions had near perfect agreement ([kappa Kappa
Used in regression analysis, Kappa represents the ratio of the dollar price change in the price of an option to a 1% change in the expected price volatility.
Remember, the price of the option increases simultaneously with the volatility. ]: 0.81-1.0), 10 had substantial agreement ([kappa]: 0.61-0.80), and four had moderate agreement ([kappa]: 0.41-0.60) according to according to
1. As stated or indicated by; on the authority of: according to historians.
2. In keeping with: according to instructions.
3. Landis and Koch (1977) criteria. [kappa] could not be calculated for the remaining one condition (i.e., psychosis) due to its low frequency in the sample. After the agreement study, two reviewers started chart reviews. In the period of data collection, they discussed cases with uncertainty in determining conditions to ensure the consistency between them.
The two reviewers examined the entire chart, including the cover page, discharge summaries, narrative summaries, pathology reports (including autopsy reports), trauma and resuscitation resuscitation /re·sus·ci·ta·tion/ (-sus?i-ta´shun) restoration to life of one apparently dead.
cardiopulmonary resuscitation records, admission notes, consultation reports, surgery/operative reports, anesthesia reports, physician daily progress notes (nursing notes excluded), physician orders, diagnostic reports, and transfer notes for evidence of any of the 32 conditions. This detailed chart review process took approximately 1 hour per chart.
Aside from the difference in the average length of time per chart between reviewers (1 hour) and coders (15-20 minutes), reviewers focused on determining presence or absence of medical conditions See carpal tunnel syndrome, computer vision syndrome, dry eyes and deep vein thrombosis. based on all documented information in the chart, including diagnostic imaging and laboratory results. This is in contrast to general coding guidelines (Canadian Institute of Health Information 2007) that instruct coders to confine their coding to clinical problems, conditions, or circumstances that are identified in the record by the treating physicians as the clinically significant reason for the patient's admission, or that require or influence evaluation, treatment, management, or care. Coders do not typically code problems that do not meet these requirements, whereas the reviewers who conducted our "reference standard" chart review included them regardless of the significance of the condition on resource use during hospitalization. Coders are instructed that when a condition is suggested by diagnostic test results, they should only code the condition if it has been confirmed by physician documentation.
Three databases were thus created for the same hospital discharges: (1) ICD-10 discharge abstract data, (2) ICD-9-CM discharge abstract data, and (3) chart review data. The databases allowed us to calculate sensitivity, specificity, positive predictive value Positive predictive value (PPV)
The probability that a person with a positive test result has, or will get, the disease.
Mentioned in: Genetic Testing
positive predictive value , and negative predictive value The negative predictive value is the proportion of patients with negative test results who are correctly diagnosed. Worked example
(as determined by "Gold standard")
True False for each condition recorded in ICD-10 hospital discharge data and then in ICD-9-CM discharge data, accepting the chart review data as a "reference standard." Recognizing that some might question the use of chart review data as a reference standard, the [kappa] statistic was also used to assess the agreement between the two databases for individual conditions. For each condition identified in the chart data, McNemar's test In statistics, McNemar's test is a non-parametric method used on nominal data to determine whether the row and column marginal frequencies are equal. It is named after Q. McNemar, who introduced it in 1947. was used to compare the sensitivity and specificity of ICD-10 versus ICD-D-CM data relative to the chart review data for detecting the conditions. To implement McNemar's statistical test for estimates of sensitivity and specificity, records with and then without a given condition present, respectively, based on chart data, were selected and agreement between ICD-9-CM and ICD-10 was tested in the subsample sub·sam·ple
A sample drawn from a larger sample.
tr.v. sub·sam·pled, sub·sam·pling, sub·sam·ples
To take a subsample from (a larger sample). .
Table 1 presents the frequency of the 32 conditions by data source among 4,008 records. Compared with the chart review data, the ICD-9-CM data underreported 29 conditions, slightly overreported two conditions (diabetes with complications and renal failure renal failure
Acute or chronic malfunction of the kidneys resulting from any of a number of causes, including infection, trauma, toxins, hemodynamic abnormalities, and autoimmune disease, and often resulting in systemic symptoms, especially edema, ), and equivalently reported one condition (deficiency anemia). The ICD-10 data underreported 31 conditions and slightly over-reported one condition (renal failure). ICD-10 data had a significantly lower frequency for eight conditions eight conditions
an acupuncture term for one of the ways of making a diagnosis. Each of the conditions is expressed as a pair of opposites, Yin and Yang, internal and external, hot and cold, deficiency and excess. and higher frequency for three conditions compared with ICD-9-CM data.
Table 2 presents five quantitative indices to assess whether the administrative data accurately reproduced what was recorded in the patient charts by data source. Sensitivity was calculated to measure the extent of recording the presence of conditions in administrative data when these were present in the chart review data. Sensitivity for ICD-9-CM and ICD-10 data varied greatly by condition. Metastatic cancer Metastatic cancer
A cancer that has spread to an organ or tissue from a primary cancer located elsewhere in the body.
Mentioned in: Liver Cancer
metastatic cancer had the highest sensitivity (83.1 percent in ICD-9-CM and 80.8 percent in ICD-10) and weight loss had the lowest sensitivity (9.3 percent in ICD-9-CM and 12.7 percent in ICD-10). Compared with ICD-10 data, ICD-9-CM data had significantly higher sensitivity for seven conditions and lower sensitivity for one condition. Sensitivity for the remaining 24 conditions was similar between ICD-9-CM and ICD-10 (see Table 2 and Figure 1). Positive predictive value, which determines the extent to which a condition present in the administrative data was also present in the chart review data, was higher than 75 percent for 20 conditions in ICD-9-CM and for 18 conditions in ICD-10 data. Specificity was used to determine the extent of reporting absence of these conditions in the administrative data when these diseases were absent in the charts. Negative predictive value was also used to determine the extent to which a condition absent in the administrative data was truly absent according to the chart review data. Specificity was higher than 98 percent for 29 conditions in ICD-9-CM (96.5 percent for solid tumor without metastasis metastasis /me·tas·ta·sis/ (me-tas´tah-sis) pl. metas´tases
1. transfer of disease from one organ or part of the body to another not directly connected with it, due either to transfer of pathogenic microorganisms or to , 97.7 percent for drug abuse, and 94.4 percent for depression) and for all 32 conditions in ICD-10. Negative predictive value was higher than 98 percent for 12 conditions in ICD-9-CM and 13 conditions in ICD-10. Cardiac arrhythmias had the lowest negative predictive value in both datasets (85.8 percent in ICD-9-CM and 85.3 percent in ICD-10).
The [kappa] value indicates that a near perfect agreement ([kappa]: 0.81-1.0 between coded data and chart review data) was found for two conditions in ICD-9-CM and one in ICD-10 data, substantial agreement ([kappa]: 0.61-0.80) for 13 conditions in ICD-9-CM and 11 conditions in ICD-10, moderate agreement ([kappa]: 0.41-0.60) for 10 conditions in ICD-9-CM and 15 conditions in ICD-10 and fair agreement ([kappa]: 0.21-0.40) for six conditions in ICD-9-CM and five conditions in ICD-10. [kappa] values relative to chart review data were generally similar for the ICD-9-CM and ICD-10 data for 29 conditions, but were discrepant dis·crep·ant
Marked by discrepancy; disagreeing.
[Middle English discrepaunt, from Latin discrep for HIV/ AIDS, hypothyroidism hypothyroidism: see thyroid gland. , and dementia (see Table 2 and Figure 2).
[FIGURE 1 OMITTED]
Our study documented the validity of ICD-9-CM and ICD-10 coding systems in coding clinical information. We found that ICD-10 administrative data were coded reasonably well on 32 conditions but that some conditions tended to be underdetected in ICD-10 data and had low validity relative to chart review data. The validity of ICD-10 data was generally comparable with that of ICD-9-CM data in recording clinical information, although ICD-9-CM coding demonstrated better sensitivity for a few conditions.
We anticipated that the new coding system had the potential to produce better validity relative to ICD-9-CM due to the new structure of codes in ICD-10 that may enhance the accuracy and specificity of code identification. In this regard, ICD-10 partially reflects the advancement of medical knowledge of the past two decades. Yet, despite this potential for greater validity, our early validity assessment (performed 9 months after the implementation of ICD-10 coding) shows that sensitivity in ICD-10 was significantly lower than that in ICD-9-CM for myocardial infarction myocardial infarction: see under infarction. , hypertension, hypothyroidism, fluid and electrolyte disorders Electrolyte Disorders Definition
An electrolyte disorder is an imbalance of certain ionized salts (i.e., bicarbonate, calcium, chloride, magnesium, phosphate, potassium, and sodium) in the blood. , obesity, drug abuse, and depression but higher in ICD-10 than in ICD-9-CM for dementia. The first possible explanation for the lower sensitivity in ICD-10 for several of the conditions is that coders were still in the early portion of an ICD-10 learning curve. The high sensitivity for dementia in ICD-10, meanwhile, may be related to the fact that ICD-10 groups dementias together as dementia in Alzheimer's disease Alzheimer's disease (ăls`hī'mərz, ôls–), degenerative disease of nerve cells in the cerebral cortex that leads to atrophy of the brain and senile dementia. (F00), vascular dementia vascular dementia
A steplike deterioration in intellectual functions that result from multiple infarctions of the cerebral hemispheres. Also called multi-infarct dementia. (F01), dementia in other diseases classified elsewhere (F02), and unspecified dementia (F03). In contrast, ICD-9-CM does not group dementias together in the coding system as is done in ICD-10. The detailed grouping of "dementia" in ICD-10 may thus facilitate the work of coders in locating dementia codes, with the downstream result being an increase in the accuracy of coding. In contrast, there are no substantial enhancements in ICD-10 relative to ICD-9-CM in disease grouping and/or code descriptions for myocardial infarction and hypertension. For example, ICD-10 and ICD-9-CM were perfectly matched for hypertension codes 110.x/401.x-115.x/405.x. The second possible explanation is that our coders who recoded charts in ICD-9-CM performed better than regular coders who coded ICD-10. About 16,000 charts were coded per year in Alberta. Coders rotate among hospital sites and are supervised under one manager within a health region. We recruited four coders who were working in the Health Records departments of the teaching hospitals studied and instructed them to code charts as they routinely do, following usual coding guidelines. Our coders coded 5.3 diagnoses per chart on average with median of four diagnoses in ICD-9-CM, which is very similar to the provincial average of 5.1 diagnoses per chart and median of four diagnoses in fiscal year 2001/2002 ICD-9-CM data. It therefore seems unlikely that the study coders performed better than regular coders. The third possible explanation is that our coders may have been randomly assigned to recode Verb 1. recode - put into a different code; rearrange mentally; "People recode and restructure information in order to remember it"
rearrange - put into a new order or arrangement; "Please rearrange these files"; "rearrange the furniture in my room" in ICD-9-CM some of the same charts that they had earlier coded in ICD-10 through their primary employment, thereby inflating the apparent similarity in performance between the two coding systems. While possible, we consider such a scenario to be infrequent, and also unlikely to have a major effect on the quality of our recoding. We randomly selected only 4,008 charts out of a total of about 70,000 (5.7 percent). Bearing in mind these numbers, it is quite unlikely for one of our coders to code the same randomly selected chart in the both ICD-9-CM and ICD-10. And even if this did occur on a few occasions, it would be quite difficult for a coder to remember much about the first time they coded a given chart. We therefore doubt that this scenario has occurred much and/or affected our results and conclusions significantly.
[FIGURE 2 OMITTED]
ICD-9-CM administrative data have been validated using various methodologies for various purposes. Hsia et al. (1992) assessed the accuracy of claims data by measuring incorrect grouping of clinically interrelated diagnostic codes with diagnosis-related groups (DRGs) and found that incorrect assignment of DRGs decreased significantly from 21 percent in 1985 to 15 percent in 1988. Many other investigators (Iezzoni et al. 1988; Jollis et al. 1993; Romano and Mark 1994; Geraci et al. 1997; Muhajarine et al. 1997; Weingart et al. 2000; Best et al. 2002; Quan, Parson PARSON, eccl. law. One who has full possession of all the rights of a parochial church.
2. He is so called because by his person the church, which is an invisible body, is represented: in England he is himself a body corporate it order to protect and defend the , and Ghali 2002; Romano et al. 2002; Lee et al. 2005; Yasmeen et al. 2006) conducted validation studies focusing on comorbidities, clinical conditions, and complications of substandard care, and found that administrative data are accurately coded for many severe or life-threatening conditions such as myocardial infarction and cancer, but that some clinically nonspecific nonspecific /non·spe·cif·ic/ (non?spi-sif´ik)
1. not due to any single known cause.
2. not directed against a particular agent, but rather having a general effect.
1. and symptomatic conditions such as rheumatologic disease, are less accurately coded.
The introduction of the new coding system, ICD-10, raises new questions about the coding accuracy and completeness of clinical information recorded in administrative data and whether there have been changes in the magnitude of coders' errors between ICD-9-CM and ICD-10 coding systems. Anderson and Robenberg (2003) analyzed cause of death before and after implementation of ICD-10 in the United States. They found that the ranking of leading causes of death was substantially changed due to changes in classification system from ICD-9 to ICD-10. For example, chronic liver disease Chronic liver disease is a liver disease of slow process and persisting over a long period of time, resulting in a progressive destruction of the liver.
It includes amongst others:
Irregular rhythm (arrhythmia) of contraction of the atria (upper heart chambers). The most common major arrhythmia, it may result as a consequence of increased fibrous tissue in the aging heart, of heart disease, or in association with severe infection. , coronary artery coronary artery
1. An artery with origin in the right aortic sinus; with distribution to the right side of the heart in the coronary sulcus, and with branches to the right atrium and ventricle, including the atrioventricular branches and disease/ischemic heart disease, diabetes mellitus diabetes mellitus
Disorder of insufficient production of or reduced sensitivity to insulin. Insulin, synthesized in the islets of Langerhans (see Langerhans, islets of), is necessary to metabolize glucose. In diabetes, blood sugar levels increase (hyperglycemia). , and hypertension were recorded significantly better than the factors of history of cerebrovascular disease cerebrovascular disease Neurology Any vascular disease affecting cerebral arteries–eg ASHD, diabetic vasculopathy, HTN, which may cause a CVA or TIA with neurologic sequelae–speech, vision, movement of variable duration. , hyperlipidemia hyperlipidemia /hy·per·lip·id·emia/ (-lip?i-de´me-ah) elevated concentrations of any or all of the lipids in the plasma, including hypertriglyceridemia, hypercholesterolemia, etc. , renal failure, and tobacco use in both ICD-9-CM and ICD-10 databases. Henderson, Shepheard, and Sundararajan (2006) compared routinely coded ICD-10 data with audit data from public hospitals in Australia This is a list of major hospitals in Australia. New South Wales
Public hospitals in New South Wales are organised into eight Area Health Services plus The Children's Hospital at Westmead. and demonstrated that the transition of the coding from ICD-9-CM to ICD-10 did not noticeably affect the quality of administrative data. Our study of dually coded data thus adds to this growing body of literature on ICD-10 validity, and like previous studies suggests that ICD-10 data have generally comparable validity, but that they do not (at least yet) have better validity than do ICD-9-CM data.
A number of conditions had poor validity in both ICD-9-CM and ICD-10 administrative data. The poor coding of certain conditions such as weight lost, obesity, and certain anemia may relate to the fact that coders do not code these conditions even if they are documented in charts, because they may not be explicitly mentioned by nurses or physicians in clinical notes, and also because they may not affect length of stay, health care, or therapeutic treatment. Additionally, coders may intentionally not code these conditions due to the limited amount of time given to code each chart.
This study has limitations. A first limitation is that we reviewed charts only in teaching hospitals. We acknowledge that a study of nonteaching hospitals is also needed. Iezzoni et al. (1988, 1990) reported that the validity of administrative data vaiies between teaching and nonteaching hospitals. At nonteaching hospitals, acute clinical conditions tend to be more accurately documented but chronic coexisting diseases are less completely recorded than at teaching hospitals. A second limitation is that we employed chart data extracted by reviewers as a "reference standard" to assess the validity of ICD-9-CM and ICD-10 data. Such a criterion standard depends on the quality of charts and could only reflect part of the validity of administrative data. Ideally, a validity study should assess whether a condition that is truly present in a patient, and this depends on whether a condition is recorded correctly in the chart, and then subsequently coded precisely in the administrative data. Therefore, this study does not capture errors that could occur when clinicians take histories, make diagnoses, or record clinical information on charts (O'Malley et al. 2005). A third limitation is that the validity of administrative data may vary across hospitals, across regions, and across countries. Therefore, our findings may not be applicable to other regions.
Weighing against these limitations are some notable study strengths. Our study is perhaps the first to undertake a direct comparison of ICD-9-CM versus ICD-10 in dually coded administrative data. We studied a large number of hospital discharge records and thus achieved good precision of our validity measures for many of the conditions studied. We also used new ICD-9-CM and ICD-10 coding algorithms (Quan et al. 2005) to define conditions that are likely to optimize administrative data validity for capturing the clinical conditions.
In conclusion, our analysis of a unique dually coded database demonstrated that ICD-9-CM and ICD-10 administrative data were coded reasonably well and had similar validity in recording clinical condition information. The implementation of ICD-10 coding did not lead to an improvement in the coding of clinical conditions. However, we assessed hospital discharge data quality relatively early after implementation of ICD-10. The longer term impact of ICD-10 on data quality will need to be assessed in future studies.
This study was supported by an operating grant from the Canadian Institutes of Health Research Canadian Institutes of Health Research (CIHR) is the major federal agency responsible for funding health research in Canada. It is the successor to the Medical Research Council of Canada. , Canada. Dr. Quan is supported by a Population Health Investigator Award from the Alberta Heritage Foundation for Medical Research, Edmonton, Alberta, Canada and by a New Investigator Certain scientific funding agencies make a distinction between investigators and new investigators. New investigators would be evaluated in a different way when competing for funding with more seasoned researchers, or they would be able to access funding resources specific to them. Award from the Canadian Institutes of Health Research. Dr. Ghali is supported by a Senior Health Scholar Award from the Alberta Heritage Foundation for Medical Research, Alberta, Canada, and by a Government of Canada The Government of Canada is the federal government of Canada. The powers and structure of the federal government are set out in the Constitution of Canada.
In modern Canadian use, the term "government" (or "federal government") refers broadly to the cabinet of the day and Research Chair in Health Services Research Health services research is the multidisciplinary field of scientific investigation that studies how social factors, financing systems, organizational structures and processes, health technologies, and personal behaviors affect access to health care, the quality and cost of health care, . The authors thank 3M for providing 3M[TM] Codefinder[TM] ICD-9-CM code searching software.
IMECCHI (International Methodology Consortium for Coded Health Information) investigators include Bernard Burnand, University of Lausanne The University of Lausanne (in French: Université de Lausanne) or UNIL in Lausanne, Switzerland was founded in 1537 as a school of theology, before being made a university in 1890. Today about 10,000 students and 2200 researchers study and work at the university. , Switzerland; Cyrille Colin, University of Lyon The University of Lyon (Université de Lyon), located in Lyon, France, comprises 16 institutions of higher education. The three main "sub-universities" are called faculties (facultés in French). , France; Chantal Couris, University of Lyon, France; Carolyn De Coster Cos´ter
n. 1. One who hawks about fruit, green vegetables, fish, etc. , University of Manitoba Location
The main Fort Garry campus is a complex on the Red River in south Winnipeg. It has an area of 2.74 square kilometres. More than 60 major buildings support the teaching and research programs of the university. , Canada; Saskia Drossler, Niederrhein University of Applied Sciences, Germany; Alan Finlayson, the National Health Service in Scotland, U.K.; Kiyohide Fushimi, Tokyo Medical and Dental University Tokyo Medical and Dental University (東京医科歯科大学 tōkyō ika shika daigaku) offers baccalaureate and graduate degrees in medicine, dentistry, and related fields. Graduate School, Japan; Min Gao, British Columbia British Columbia, province (2001 pop. 3,907,738), 366,255 sq mi (948,600 sq km), including 6,976 sq mi (18,068 sq km) of water surface, W Canada. Geography
Provincial Public Health Services health services Managed care The benefits covered under a health contract Authority, Canada; William Ghali, University of Calgary, Canada; Patricia Halfon, University of Lausanne, Switzerland; Brenda Hemmelgarn, University of Calgary, Canada; Karin Humphties, University of British Columbia Locations
The Vancouver campus is located at Point Grey, a twenty-minute drive from downtown Vancouver. It is near several beaches and has views of the North Shore mountains. The 7. , Canada; Jean-Marie Januel, University of Lausanne, Switzerland; Helen Johansen, Statistics Canada; Lisa Lix, Universality of Manitoba, Canada;Jean-Christophe Luthi, University of Lausanne, Switzerland; Jin Ma, Jiaotong University Jiaotong University, Jiao Tong University or Chiao Tung University was the predecessor of the following universities:
v. shrove or shrived, shriv·en or shrived, shriv·ing, shrives
1. To hear the confession of and give absolution to (a penitent).
2. , University of Calgary, Canada; Vijaya Sundararajan, Victorian Department of Human Services, Australia; Jack Tu, University of Toronto Research at the University of Toronto has been responsible for the world's first electronic heart pacemaker, artificial larynx, single-lung transplant, nerve transplant, artificial pancreas, chemical laser, G-suit, the first practical electron microscope, the first cloning of T-cells, , Canada; Sandrine Touzet, University of Lyon, France; and Greg Webster, Canadian Institute of Health Information, Canada.
Disclosures. No any conflicts of interest.
Anderson, R.N., and H.M. Rosenberg. 2003. "Disease Classification: Measuring the Effect of the Tenth Revision of the International Classification of Diseases on Cause-of-Death Data in the United States." Statistics in Medicine 22: 1551-70.
Best, W.R., S.F. Khuri, M. Phelan, K. Hur, W.G. Henderson, J.G. Demakis, and J. Daley. 2002. "Identifying Patient Preoperative pre·op·er·a·tive
Preceding a surgical operation.
preceding an operation.
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Hude Quan, Bing Li, L. Duncan Saunder, Gerry A. Parsons, Carolyn I. Nilsson, Arif Alibhai, and William A. Ghali for the IMECCHI Investigators
Address correspondence to Hude Quan, M.D., Ph.D., Department of Community Health Sciences and Centre for Health and Policy Studies, University of Calgary, 3330 Hospital Dr. NW, Calgary, AB, Canada T2N 4N1. Bing Li, M.A., is with the Calgary Health Region Calgary Health Region is the governing body for healthcare regulation in an area of the Canadian province of Alberta. The region administers facilities in the communities of:
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Table 1: Frequency of Clinical Condition by Data Source (%) Chart ICD-9- Conditions Data CM Data In Charlson Index Myocardial infarction 12.8 9.6 Cerebrovascular disease 8.1 4.6 Rheumatic disease 2.6 1.0 Dementia 3.3 1.1 In Elixhauser Index Cardiac arrhythmias 21.8 9.4 Pulmonary circulation 2.7 1.6 disorders Valvular disease 7.0 3.2 Hypertension 30.2 25.2 Hypothyroidism 8.8 6.2 Lymphoma 1.0 0.9 Solid tumor without 9.5 7.4 metastasis Renal failure 4.0 4.6 Blood loss anemia 1.1 0.7 Deficiency anemia 1.9 1.9 Coagulopathy 7.7 1.8 Fluid and electrolyte 11.1 6.1 disorders Weight loss 3.7 0.5 Obesity 8.3 2.7 Alcohol abuse 7.4 4.8 Drug abuse 4.9 3.7 Psychoses 2.9 2.1 Depression 11.9 7.3 In Both Charlson and Elixhauser Indices Congestive heart failure 8.3 6.6 Peripheral vascular disease 4.3 2.9 Hemiplegia or paraplegia 1.6 1.1 Chronic pulmonary disease 15.0 9.0 Diabetes with complication 2.7 2.8 Diabetes without 11.9 10.7 complication Peptic ulcer disease 2.5 1.1 Metastatic cancer 4.4 4.1 Liver disease 5.0 2.4 AIDS/HIV 0.6 0.2 Difference ICD-10 Chart- Conditions Data ICU-9-CM In Charlson Index Myocardial infarction 8.4 3.2 Cerebrovascular disease 4.0 3.0 Rheumatic disease 1.4 1.1 Dementia 2.4 2.2 In Elixhauser Index Cardiac arrhythmias 9.1 12.4 Pulmonary circulation 1.6 1.1 disorders Valvular disease 3.0 3.8 Hypertension 22.2 5.0 Hypothyroidism 3.7 2.6 Lymphoma 0.8 0.1 Solid tumor without 7.4 2.1 metastasis Renal failure 4.9 -0.6 Blood loss anemia 0.6 0.4 Deficiency anemia 1.4 0.0 Coagulopathy 1.8 0.5 Fluid and electrolyte 5.6 5.0 disorders Weight loss 0.9 3.2 Obesity 19.0 0.5 Alcohol abuse 4.6 2.6 Drug abuse 2.8 1.2 Psychoses 1.8 0.8 Depression 5.8 4.6 In Both Charlson and Elixhauser Indices Congestive heart failure 6.3 1.7 Peripheral vascular disease 2.8 1.4 Hemiplegia or paraplegia 1.4 0.5 Chronic pulmonary disease 8.7 6.0 Diabetes with complication 2.6 -0.1 Diabetes without 10.2 1.2 complication Peptic ulcer disease 1.3 1.4 Metastatic cancer 1.1 0.3 Liver disease 2.4 2.6 AIDS/HIV 0.3 0.4 Difference p- Value Chart- ICD-9-CM Conditions ICD-10 versus ICD-10 In Charlson Index Myocardial infarction 4.4 <.001 Cerebrovascular disease 3.6 .642 Rheumatic disease 1.2 .683 Dementia 0.9 <.001 In Elixhauser Index Cardiac arrhythmias 12.7 .241 Pulmonary circulation 1.1 .578 disorders Valvular disease 3.0 .134 Hypertension 8.0 <.001 Hypothyroidism 5.1 <.001 Lymphoma 0.2 .157 Solid tumor without 2.1 .736 metastasis Renal failure -0.9 .180 Blood loss anemia 0.5 .858 Deficiency anemia 0.5 .011 Coagulopathy 0.5 1.000 Fluid and electrolyte 5.5 .089 disorders Weight loss 2.8 .016 Obesity 6.4 <.001 Alcohol abuse 2.8 .477 Drug abuse 2.1 <.001 Psychoses 1.1 .048 Depression 6.1 <.001 In Both Charlson and Elixhauser Indices Congestive heart failure 2.0 .281 Peripheral vascular disease 1.5 .000 Hemiplegia or paraplegia 0.2 .028 Chronic pulmonary disease 6.3 .440 Diabetes with complication 0.1 .292 Diabetes without 1.7 .114 complication Peptic ulcer disease 1.2 .088 Metastatic cancer 0.3 1.000 Liver disease 2.6 1.000 AIDS/HIV 0.3 .103 ICD-9-CM, ICD-9 Clinical Modification; ICD-10, International Classification of Disease, 10th Version. Table 2: Agreement between Chart and Administrative Data (%) ICD-9-CM Data Conditions Sensitivity PPV Specificity In Charlson Index Myocardial infarction 72.4 95.9 99.5 Cerebrovascular disease 46.3 81.2 99.1 Rheumatic disease 51.0 89.8 99.9 Dementia 32.3 95.6 100 In Elixhauder Index Cardiac arrhythmias 41.1 9.5 99.4 Pulmonary circulation 34.3 59.7 99.4 disorders Valvular disease 38.4 82.3 99.4 Hypertension 78.6 94.0 98.0 Hypothyroidism 65.3 92.8 99.5 Lymphoma 65.9 73.0 99.8 Solid tumor without 43.8 56.6 96.5 metastasis Renal failure 81.9 71.2 98.6 Blood loss anemia 13.3 23.1 99.5 Deficiency anemia 38.2 39.2 98.9 Coagulopathy 12.9 5.5 99.1 Fluid and electrolyte 42.4 76.7 98.4 disorders Weight loss 9.3 66.7 99.8 Obesity 24.6 75.9 99.3 Alcohol abuse 53.6 82.7 99.1 Drug abuse 55.3 73.7 99.0 Psychoses 57.8 79.8 99.6 Depression 56.6 92.8 99.4 In Both Charlson and Elixhauser Indices Congestive heart failure 71.6 90.5 99.3 Peripheral vascular 46.2 67.0 99.0 disease Hemiplegia or paraplegia 43.6 62.8 99.6 Chronic pulmonary disease 54.9 91.9 99.2 Diabetes with chronic 63.6 62.5 98.9 complication Diabetes without chronic 77.7 86.5 98.4 complication Peptic ulcer disease 36.6 84.1 99.8 Metastatic cancer 83.1 89.1 99.5 Liver disease 38.1 80.2 99.5 AIDS/HIV 25.0 100 100 ICD-9-CM Data ICD-10 Data Conditions NPV [kappa] Sensitivity In Charlson Index Myocardial infarction 96.1 0.8 61.5 Cerebrovascular disease 95.4 0.6 46.3 Rheumatic disease 98.7 0.6 52.9 Dementia 97.7 0.5 66.9 In Elixhauder Index Cardiac arrhythmias 85.8 0.5 39.0 Pulmonary circulation 98.2 0.4 37.0 disorders Valvular disease 95.6 0.5 40.9 Hypertension 91.4 0.8 68.3 Hypothyroidism 96.7 0.8 39.3 Lymphoma 99.7 0.7 63.4 Solid tumor without 94.2 0.5 45.9 metastasis Renal failure 99.2 0.8 78.8 Blood loss anemia 99.0 0.2 17.8 Deficiency anemia 98.8 0.4 30.3 Coagulopathy 93.2 0.2 13.9 Fluid and electrolyte 93.2 0.5 36.3 disorders Weight loss 96.6 0.2 12.7 Obesity 93.6 0.4 18.6 Alcohol abuse 96.4 0.6 52.2 Drug abuse 97.7 0.6 46.7 Psychoses 98.8 0.7 56.9 Depression 94.4 0.7 44.9 In Both Charlson and Elixhauser Indices Congestive heart failure 97.5 0.8 68.6 Peripheral vascular 97.6 0.5 43.3 disease Hemiplegia or paraplegia 99.1 0.5 53.2 Chronic pulmonary disease 92.6 0.7 52.8 Diabetes with chronic 99.0 0.6 59.1 complication Diabetes without chronic 97.0 0.8 75.8 complication Peptic ulcer disease 98.4 0.5 39.6 Metastatic cancer 99.2 0.9 80.8 Liver disease 96.8 0.5 40.6 AIDS/HIV 99.6 0.4 41.7 ICD-10 Data Conditions PPV Specificity NPV In Charlson Index Myocardial infarction 93.5 99.4 94.6 Cerebrovascular disease 83.0 99.2 95.4 Rheumatic disease 96.5 100 98.8 Dementia 92.7 99.8 98.9 In Elixhauder Index Cardiac arrhythmias 93.4 99.2 85.3 Pulmonary circulation 61.5 99.4 98.3 disorders Valvular disease 80.3 99.3 95.7 Hypertension 93.1 97.8 87.7 Hypothyroidism 93.3 99.7 94.4 Lymphoma 78.8 99.8 99.6 Solid tumor without 58.7 96.6 94.5 metastasis Renal failure 64.3 98.2 99.1 Blood loss anemia 32.0 99.6 99.1 Deficiency anemia 40.4 99.1 98.7 Coagulopathy 0.6 99.2 93.2 Fluid and electrolyte 71.6 98.2 92.6 disorders Weight loss 55.9 99.6 96.7 Obesity 83.8 99.7 93.1 Alcohol abuse 83.7 99.2 96.3 Drug abuse 81.4 99.5 97.3 Psychoses 90.4 99.8 98.7 Depression 91.5 99.4 93.0 In Both Charlson and Elixhauser Indices Congestive heart failure 90.2 99.3 97.2 Peripheral vascular 65.5 99.0 97.5 disease Hemiplegia or paraplegia 58.9 99.4 99.3 Chronic pulmonary disease 90.8 99.1 92.2 Diabetes with chronic 63.1 99.0 98.9 complication Diabetes without chronic 88.5 98.7 96.8 complication Peptic ulcer disease 76.9 99.7 98.5 Metastatic cancer 86.7 99.4 99.1 Liver disease 85.4 99.6 96.9 AIDS/HIV 100 100 99.7 p-Value ICD-9-CM ICD-10 Data versus ICD-10 Conditions [kappa] Sensitivity Specificity In Charlson Index Myocardial infarction 0.71 <0.001 .221 Cerebrovascular disease 0.57 1.000 .433 Rheumatic disease 0.68 0.637 .103 Dementia 0.77 <0.001 .059 In Elixhauder Index Cardiac arrhythmias 0.48 0.056 .221 Pulmonary circulation 0.45 0.439 1.000 disorders Valvular disease 0.52 0.307 .225 Hypertension 0.72 <0.001 .414 Hypothyroidism 0.53 <0.001 .021 Lymphoma 0.70 0.564 .180 Solid tumor without 0.47 0.228 .398 metastasis Renal failure 0.69 0.411 .010 Blood loss anemia 0.22 0.414 .549 Deficiency anemia 0.34 0.083 .056 Coagulopathy 0.20 0.532 .549 Fluid and electrolyte 0.44 0.005 .297 disorders Weight loss 0.20 0.197 .033 Obesity 0.28 0.006 .003 Alcohol abuse 0.62 0.623 .000 Drug abuse 0.58 0.001 .002 Psychoses 0.69 0.763 .020 Depression 0.59 <0.001 .808 In Both Charlson and Elixhauser Indices Congestive heart failure 0.76 0.197 1.000 Peripheral vascular 0.50 0.423 1.000 disease Hemiplegia or paraplegia 0.55 0.109 .127 Chronic pulmonary disease 0.63 0.267 .590 Diabetes with chronic 0.60 0.384 .527 complication Diabetes without chronic 0.79 0.389 .124 complication Peptic ulcer disease 0.52 0.467 .025 Metastatic cancer 0.83 0.433 .650 Liver disease 0.54 0.384 .275 AIDS/HIV 0.59 0.103 1.000 Note: PPV, positive predictive value; NPV, negative predictive value; ICD-9-CM, ICD-9 Clinical Modification; ICD-10, International Classification of Disease, 10th Version.