Nonspecific Codes Research Articles

Use of multiple imputation to correct for bias in lung cancer incidence trends by histologic subtype.

Over the past several decades, advances in lung cancer research and practice have led to refinements of histologic diagnosis of lung cancer. The differential use and subsequent alterations of nonspecific morphology codes, however, may have caused artifactual fluctuations in the incidence rates for histologic subtypes, thus biasing temporal trends. We developed a multiple imputation (MI) method to correct lung cancer incidence for nonspecific histology using data from the Surveillance, Epidemiology, and End Results Program during 1975 to 2010. For adenocarcinoma in men and squamous in both genders, the change to an increasing trend around 2005, after more than 10 years of decreasing incidence, is apparently an artifact of the changes in histopathology practice and coding system. After imputation, the rates remained decreasing for adenocarcinoma and squamous in men, and became constant for squamous in women. As molecular features of distinct histologies are increasingly identified by new technologies, accurate histologic distinctions are becoming increasingly relevant to more effective "targeted" therapies, and therefore, are important to track in patients. However, without incorporating the coding changes, the incidence trends estimated for histologic subtypes could be misleading. The MI approach provides a valuable tool for bridging the different histology definitions, thus permitting meaningful inferences about the long-term trends of lung cancer by histologic subtype.

Development and evaluation of an algorithm to identify users of Prolia® during the early postmarketing period using health insurance claims data

The goal of this study is to develop and validate an algorithm to identify Prolia(®) users within a health insurance claims database. Patients with a denosumab-specific or nonspecific administration claim during the early period of Prolia availability in the USA (June 1, 2010 to March 31, 2012) were classified as definite, probable, possible, and nonusers of Prolia using an algorithm consisting of nine different components based on claims patterns consistent with Prolia use. Medical record review confirmed a sample of definite, probable, and possible users and the positive predictive value (PPV) was estimated. The PPV of the claims-based algorithm components varied (17.8-95.8%). Requiring claims for a bone or cartilage disorder or osteoporotic fracture after excluding claims for cancer prior to a denosumab-specific administration code gave the highest PPV (95.8%), followed by requiring a Prolia National Drug Code on the same claim as a denosumab-specific or nonspecific administration code (88.2%). Among the 87 confirmed Prolia users, osteoporosis diagnoses were seen more frequently in the medical record than in claims (83% vs 62%). Prolia users are most accurately identified with administration code claims in conjunction with claims for Prolia National Drug Code and bone disorder treatment and diagnosis codes. Osteoporosis diagnoses may be under-recorded in claims data. The algorithm may require reassessment as uptake for more recently approved indications increases.

Identifying newly approved medications in Medicare claims data: a case study using tocilizumab

After U.S. licensure, parenterally administered medications are identified using non-specific drug codes. Accurately identifying these medications is critical to safety and effectiveness research. Methods to identify medications prior to assignment of specific drug codes have not been well described. To describe a generalized approach using non-specific drug codes to identify parenteral therapies in Medicare claims and to assess the ability of that approach to identify tocilizumab (TCZ), a new biologic agent approved in 2010. We used 2008-2010 Medicare data for a cohort of rheumatoid arthritis patients for algorithm development. Our algorithm classified non-specific drug codes based upon: 1) ICD9 codes; 2) unit values (i.e. dose); 3) codes for infusion/injection procedures; 4) expected versus observed total reimbursement amount and reimbursement per unit. We assessed algorithm performance by linking to an arthritis registry to examine external validity. Of 472 803 claims with non-specific drug codes, 9762 claims satisfied the TCZ algorithm. 74.3% of 9762 claims were classified as TCZ by exact unit price or allowed amount, 4.4% by unique doses, 21.3% by diagnosis code and small deviation from unit price or allowed amount. The algorithm demonstrated good performance characteristics: sensitivity 94% (95% CI 80-99), specificity 100% (99-100) and PPV 97% (84-100). Claims-based algorithms in Medicare or similar data systems can accurately identify newly approved biologics administered parenterally prior to the assignment of specific drug codes.

Accuracy of International Classification of Diseases, 9th Revision, Clinical Modification codes for upper gastrointestinal complications varied by position and age: a validation study in a cohort of nonsteroidal anti‐inflammatory drugs users in Friuli Venezia Giulia, Italy

To validate the International Classification of Diseases, 9th Revision, Clinical Modification discharge codes used to identify cases of upper gastrointestinal complications (UGICs) in hospitals of Friuli Venezia Giulia, Italy. Cohort study on the risk of UGIC in users of nonsteroidal anti-inflammatory drugs conducted in Friuli Venezia Giulia between 2001 and 2008. Cases were identified through primary and secondary International Classification of Diseases, 9th Revision Clinical specific codes 531 (gastric ulcer), 532 (duodenal ulcer), 533 (peptic ulcer), 534 (gastrojejunal ulcer), and nonspecific code 578 (gastrointestinal hemorrhage). Potential cases were confirmed through hospital chart review. The chart retrieval percentage was 98.4%.The positive predictive value (PPV) was 94.3% for primary codes 531 and 532, 79.5% for code 533, 83.1% for code 534, 40.2% for code 578. The PPV for secondary codes was 34.7% but increased to 88.9% and 79.2% when the primary code was for peritonitis or acute post-hemorrhagic anemia, respectively. Validation of secondary codes increased case ascertainment by 4.9%. Endoscopy confirmed 79.4% of cases but only 67.2% of those above age 84 years. The PPV was high for specific primary codes and moderate to low for nonspecific primary and secondary codes. The inclusion of confirmed cases identified by nonspecific and secondary codes can be of value in studies that need a complete ascertainment of cases occurring in the study population. In this cohort, not including these cases would underestimate the incidence of UGICs. A potential for case misclassification exists in particular in eldest ages.

Risk of upper gastrointestinal complications in a cohort of users of nimesulide and other nonsteroidal anti‐inflammatory drugs in Friuli Venezia Giulia, Italy

Information on the risk of upper gastrointestinal complications (UGIC) in users of nimesulide, the most used nonsteroidal anti-inflammatory drug (NSAID) in Italy, is scarce. In the context of the European regulatory review on nimesulide, we estimated and compared the risk associated with nimesulide and other individual NSAIDs with the risk in nonusers. We used 2001-2008 data from regional health databases in Friuli Venezia Giulia (FVG), Italy, to conduct a cohort and nested case-control study of users of NSAIDs. Cases were identified by specific and nonspecific hospital discharge diagnoses in primary and secondary position and validated through hospital records. Ten controls per case were selected using density-based sampling from the cohort. Conditional logistic regression was used to estimate adjusted relative risks (RRs) and 95% confidence intervals (CIs). The cohort included 588,827 NSAIDs users and 3031 UGIC cases. Nonspecific codes contributed to 23% of cases and secondary codes to 5%. Among current users, IR per 1000 person-years decreased from 4.45 cases in 2001 to 2.21 cases in 2008. The RR (95%CI) for current use of NSAIDs was 3.28 (2.86, 3.76). RR was <2 for rofecoxib, celecoxib, and nimesulide; 2 to <5 for naproxen, ibuprofen, diclofenac, etoricoxib, and meloxicam; and ≥ 5 for ketoprofen, piroxicam, and ketorolac. IRs of UGIC in FVG decreased about 50% between 2001 and 2008. Nimesulide was in the low-medium range of RR. A complete ascertainment of UGIC cases in databases may require validation of nonspecific codes, secondary codes, and additional codes such as peritonitis and acute posthemorrhagic anemia.

Evaluation of ICD‐9‐CM codes for craniofacial microsomia

Craniofacial microsomia (CFM) is a congenital condition characterized by microtia and mandibular underdevelopment. Healthcare databases and birth defects surveillance programs could be used to improve knowledge of CFM. However, no specific International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) code exists for this condition, which makes standardized data collection challenging. Our aim was to evaluate the validity of existing ICD-9-CM codes to identify individuals with CFM. Study sample eligibility criteria were developed by an expert panel and matched to 11 ICD-9-CM codes. We queried hospital discharge data from two craniofacial centers and identified a total of 12,254 individuals who had ≥1 potentially CFM-related code(s). We reviewed all (n = 799) medical records identified at the University of North Carolina (UNC) and 500 randomly selected records at Seattle Children's Hospital (SCH). Individuals were classified as a CFM case or non-case. Thirty-two individuals (6%) at SCH and 93 (12%) at UNC met the CFM eligibility criteria. At both centers, 59% of cases and 95% of non-cases had only one code assigned. At both centers, the most frequent codes were 744.23 (microtia), 754.0 and 756.0 (nonspecific codes), and the code 744.23 had a positive predictive value (PPV) >80% and sensitivity >70%. The code 754.0 had a sensitivity of 3% (PPV <1%) at SCH and 36% (PPV = 5%) at UNC, whereas 756.0 had a sensitivity of 38% (PPV = 5%) at SCH and 18% (PPV = 26%) at UNC. These findings suggest the need for a specific CFM code to facilitate CFM surveillance and research.

Recent Trends in the Incidence of Anxiety Diagnoses and Symptoms in Primary Care

BackgroundAnxiety is common, with significant morbidity, but little is known about presentations and recording of anxiety diagnoses and symptoms in primary care. This study aimed to determine trends in incidence and socio-demographic variation in General Practitioner (GP) recorded diagnoses of anxiety, mixed anxiety/depression, panic and anxiety symptoms.Methodology/Principal FindingsAnnual incidence rates of anxiety diagnoses and symptoms were calculated from 361 UK general practices contributing to The Health Improvement Network (THIN) database between 1998 and 2008, adjusted for year of diagnosis, gender, age, and deprivation. Incidence of GP recorded anxiety diagnosis fell from 7.9 to 4.9/1000PYAR from 1998 to 2008, while incidence of anxiety symptoms rose from 3.9 to 5.8/1000PYAR. Incidence of mixed anxiety/depression fell from 4.0 to 2.2/1000PYAR, and incidence of panic disorder fell from 0.9/1000PYAR in 1998 to 0.5/1000PYAR in 2008. All these entries were approximately twice as common in women and more common in deprived areas. GP-recorded anxiety diagnoses, symptoms and mixed anxiety/depression were commonest aged 45–64 years, whilst panic disorder/attacks were more common in those 16–44 years. GPs predominately use broad non-specific codes to record anxiety problems in the UK.Conclusions/SignificanceGP recording of anxiety diagnoses has fallen whilst recording of anxiety symptoms has increased over time. The incidence of GP recorded diagnoses of anxiety diagnoses was lower than in screened populations in primary care. The reasons for this apparent under-recording and whether it represents under-detection in those being seen, a reluctance to report anxiety to their GP, or a reluctance amongst GPs to label people with anxiety requires investigation.

Antibiotic Prophylaxis for Dental Procedures

The possibility that bacteremia from the mouth could cause infective endocarditis (IE) was first suggested >100 years ago, and it was later reinforced by others who targeted the viridans group streptococci from poor oral hygiene and dental extractions.1–3 These observations, along with the advent of antibiotics, eventually led to the first guidelines from the American Heart Association (AHA) in 1955. Antibiotic prophylaxis (AP) became the primary focus for prevention of IE and a standard of care for countries around the world. Controversy concerning efficacy and safety issues has existed for >30 years, and there has been a progressive reduction in the patient populations and the procedures suggested for AP since that time. Of concern, and in spite of a decreasing emphasis on AP for cardiac patients, upwards of 25 noncardiac patient populations are recommended for AP by some clinicians out of concern for systemic infections that might originate from dental procedures (eg, prosthetic joints).4 Article see p 60 Significant differences in recommendations from experts in the United States, United Kingdom, and other countries over the years highlight the lack of convincing data to either support or reject this practice. The National Institute for Health and Clinical Excellence (NICE) in the United Kingdom issued new recommendations in 2006, which took the bold step of eliminating AP altogether.5 Current (2007) AHA guidelines narrow the focus to only 4 cardiac groups at higher risk for a bad outcome from IE but who represent ≈10% of all people at risk for IE.6 The AHA-defined moderate-risk groups represent ≈90% of people at risk for IE, all of whom were recommended for AP before 2007. There are, therefore, no …

PIH79 Medication Adherence and Persistence for Hypogondal Patients Treated with Topical Testosterone Therapy: A Retrospective Claims Analysis

The diagnosis of hypogonadism is established in symptomatic men with consistently low levels of serum testosterone, whether due to specific diagnoses, such as Klinefelter syndrome, or non-specific diagnoses, which often occur with aging. Testosterone gels are the most common form of testosterone replacement therapy for hypogonadism in the United States, but little is known about patient adherence and persistence with therapy. This study seeks to examine testosterone gel adherence and persistence among hypogonadism patients. The type of hypogonadism (specific versus non-specific) was classified using either ICD-9-CM diagnostic codes or testosterone prescription codes in the Thomson Reuters MarketScan® Database in 2009. Medication persistence was defined as the length of therapy (LOT) from the index date to the earliest ending date of the last prescription, defined as either the date of the first gap of >30 days between prescriptions or the end of study period (12 months). Medication adherence was measured by medication possession ratio (MPR) in the 6 months follow-up period. Adherence rate was defined as percent of MPR ≥0.8. LOT, MPR and adherence rate were calculated by diagnostic code and age group and compared using t-test or chi-square test. 91,200 men met study criteria for hypogonadism: 11.1% with specific and 89.9% with non-specific diagnostic codes. The mean LOT was 196 days and 178 days, respectively (p< 0.0001). MPR and adherence rates were similar between men with specific (0.4 and 8.6%, respectively) and non-specific (0.4 and 9.0%, respectively) diagnoses. LOT, MPR and adherence rate were numerically similar across all age groups. Unexpectedly, diagnostic specificity and age were not found to be key etiologic factors in testosterone gel adherence and persistence for hypogonadal men. Unexplored factors that might provide more sensitivity include other testosterone application methods, hypogonadal symptom severity, and ascertainment of testosterone levels.

Underuse of Diagnostic Codes for Specific Dementias in the Veterans Affairs New England Healthcare System

To examine the specificity of dementia coding in large populations. Retrospective cohort and chart review study of dementia diagnosis. U.S. Department of Veterans Affairs (VA) New England healthcare system. Veterans aged 50 and older given outpatient visit codes for dementia between January 1, 2000, and December 31, 2009. The frequency of the code "dementia not otherwise specified (DNOS)" as a first and final diagnosis was determined. DNOS use was examined according to provider type and geographic location. The medical records of 100 individuals with unspecified dementia were reviewed to determine their underlying diagnoses and describe their examination. Twenty-two thousand fifty veterans diagnosed with dementia were identified over 10 years of follow-up. One-third of all cases had no specific dementia code (n = 6,659). DNOS was the most commonly used code as a first dementia diagnosis (42.5%) and was second only to Alzheimer's type dementia (35.8%) as a final diagnosis. Individuals who saw geriatricians and neurologists were most likely to have a specific dementia diagnosis, and DNOS use was lowest in centers with the most dementia specialists. Only 12% of primary care physicians performed cognitive testing the first time they used the DNOS code, compared with 98% of specialists. Nearly half of individuals with a persistent diagnosis of DNOS met criteria for a specific dementia. Substantial overuse was found of nonspecific dementia codes in the VA New England healthcare system, leading to an underestimation of the prevalence of Alzheimer's disease and other dementias. System-based changes in dementia coding and greater access to dementia specialists may help improve diagnostic specificity.

Quantifying the Underestimated Burden of Road Traffic Mortality in Mexico: A Comparison of Three Approaches

Introduction: We present a novel multistep technique to estimate the actual burden of road traffic mortality in Mexico during the time period 1999 to 2009 by comparing 3 approaches for redistribution of nonspecific (“garbage”) International Classification of Diseases (ICD)-coded deaths. Methods: Road traffic (RT) mortality data were extracted using a secondary analysis of the Mexican mortality databases for the period 1999 to 2009. In an attempt to correct for underestimation due to inappropriately coded deaths, those deaths assigned to nonspecific codes were redistributed utilizing 3 different adjustment methods. A comparison of the 3 adjustment approaches (proportional, multiple imputation, and regression) is presented. A Poisson regression analysis was utilized to model mortality trends in the raw data and the 3 estimates. Results: After adjustments, the total number of RT deaths increased by 18 to 45 percent, showing significant underestimation when only the raw data are used. All 3 approaches showed statistically significantly higher RT mortality rates than the crude figures. The proportional approach resulted in the highest RT mortality rate estimate of 23 per 100,000 in 2009 and showed a statistically significant positive increase of 1.5 percent per year across the decade. The 60+ age group and pedestrians had the highest mortality rates of 40 and 10.3 per 100,000, respectively. Over the decade, there was an alarming 332 percent increase in the mortality rate for male motorcyclists. Conclusion: Though efforts to improve coding should continue to be implemented, we present an additional and often overlooked contribution to the underestimation of road traffic mortality: the ICD nonspecific codes. Improved estimates of road traffic mortality are important in Mexico for policy change and decision making, highlighting the importance of targeting road traffic deaths as a public health problem. The approach presented here may also be useful for estimating the burden of other deaths with similar coding problems.

Cloacal exstrophy: An epidemiologic study from the International Clearinghouse for Birth Defects Surveillance and Research

Cloacal exstrophy presents as a complex abdominal wall defect thought to result from a mesodermal abnormality. Anatomically, its main components are Omphalocele, bladder Exstrophy and Imperforate anus. Other associated malformations include renal malformations and Spine defects (OEIS complex). Historically, the prevalence ranges from 1 in 200,000 to 400,000 births, with higher rates in females. Cloacal exstrophy is likely etiologically heterogeneous as suggested by its recurrence in families and occurrence in monozygotic twins. The defect has been described in infants with limb-body wall, with trisomy 18, and in one pregnancy exposed to Dilantin and diazepam. Due to its rarity, the use of a nonspecific diagnostic code for case identification, and lack of validation of the clinical findings, cloacal exstrophy remains an epidemiologic challenge. The purpose of this study was to describe the prevalence, associated anomalies and maternal characteristics among infants born with cloacal exstrophy. We used data from the International Clearinghouse for Birth Defects Surveillance and Research submitted from 18 birth defect surveillance programs representing 24 countries. Cases were clinically evaluated locally and reviewed centrally by two authors. Cases of persistent cloaca were excluded. A total of 186 cases of cloacal exstrophy were identified. Overall prevalence was 1 in 131,579 births: ranging from 1 in 44,444 births in Wales to 1 in 269,464 births in South America. Live birth prevalence was 1 in 184,195 births. Prevalence ratios did not vary by maternal age. Forty-two (22.6%) cases met the criteria for the OEIS complex, whereas 60 (32.3%) were classified as OEI and 18 (9.7%) as EIS (one with suspected VATER (0.5%)). Other findings included two cases with trisomy 13 (one without a karyotype confirmation), one with mosaic trisomy 12 (0.5%), one with mosaic 45,X (0.5%) and one classified as having amnion band sequence (0.5%). Twenty-seven (14.5%) infants had other anomalies unrelated to cloacal exstrophy. Cloacal exstrophy is a rare anomaly with variability in prevalence by geographic location. The proportion of cases classified as OEIS complex was lower in this study than previously reported. Among all cases, 54.8% were reported to have an omphalocele.

Etiology of Nonspecific Cause of Death Coding in New York City Motor Vehicle Crash–Related Fatalities

Objectives: Nearly 20 percent of New York City's (NYC) accidental deaths are related to motor vehicles crashes (MVCs). Detailed International Classification of Disease (ICD-10; World Health Organization [WHO] 2007) cause-of-death coding of MVC-related fatalities improves surveillance and resulting identification of prevention strategies. We investigated ICD-10 codes in these fatalities and the potential to make them more specific. Methods: We defined “nonspecific” MVC ICD-10 codes as all globally unspecific codes (V870–V878, V892) and any codes with nonspecific components regarding vehicle involved, decedent position in vehicle, or MVC setting. We calculated nonspecific-code frequency for 1999–2008 MVC deaths. We reviewed a random 10 percent sample of 2007–2008 MVC deaths (N = 61) and medical examiner (ME) records of all nonspecific death certificates (N = 52), including police accident reports (“full PAR”) and summaries prepared by onsite police officers (“brief PAR”) to determine whether MEs had sufficient information available but did not include that information at death certification. Results: Among 1999–2008 NYC MVC deaths, 82.9 percent had nonspecific ICD-10 cause-of-death codes. Similarly, of the 61 recent randomly sampled MVC deaths, 52 (85.2%) had nonspecific codes. Of 52 nonspecific death certificates from the random sample, 38 (73.1%) death certificates had adequate information available on full or brief PAR to be more specific at the time of death certification. Consistent with MEs’ reports of high reliance on the brief PAR, most nonspecific death certificates (76.9%) lacked adequate information in the brief PAR to be more specific. Conclusion: Specific ICD-10 codes for MVC deaths depends on the level of detail provided by the ME in the “How Injury Occurred” and “If Transportation Injury Specify” death certificates sections. We have worked to ensure that key information is available to MEs in the brief PAR and educated MEs on the importance of this information to reduce the frequency of nonspecific codes and enhance injury prevention research.

Ascertainment of Patients With Myelodysplastic Syndromes

TO THE EDITOR: In a recent article published in Journal of Clinical Oncology, Goldberg et al estimated that approximately 45,000 new cases of myelodysplastic syndromes (MDSs) were diagnosed among individuals 65 years or older in the United States in 2003. This number was surprisingly high, given that two other studies have estimated that the number of incident MDS cases is approximately 10,000 each year in the United States, and in both studies, that estimate was reportedly for all age groups combined. After a careful review of the article by Goldberg et al, we were quite concerned about how the authors ascertained MDS patients from among Medicare beneficiaries. As described by the authors, “the International Classification of Diseases for Oncology ninth edition CM (ICD-9-CM) code 238.7 was used to identify patients with a new diagnosis of MDS in calendar year 2003,” and patients with anemias of known causes or myeloid leukemia diagnosed in the previous year (2002) were excluded. It seems that the authors confused two different disease classification systems: the International Classification of Diseases, with the most recent codes contained within the 10th edition, and the International Classification of Diseases for Oncology, with the most recent codes contained within the 3rd edition. The code cited by the authors, 238.7, is an ICD-9-CM code (CM indicates clinical modification) that is not specific to MDS. Rather, it includes multiple other diseases and conditions. The American Medical Association publishes the ICD-9-CM codes annually. In the 2002 and 2003 publications, the following information was listed for code 238.7. 238.7. Other lymphatic and hematopoietic tissues. Disease: lymphoproliferative (chronic), not otherwise specified; myeloproliferative (chronic), not otherwise specified; idiopathic thrombocythemia; megakaryocytic myelosclerosis; myelodysplastic syndrome; myelosclerosis with myeloid metaplasia; panmyelosis (acute). A patient who had Medicare claims that included an ICD-9-CM code of 238.7 might have been diagnosed with MDS or one of the several other diseases or conditions designated by this code. By using a nonspecific diagnostic code, the authors included non-MDS cases in their study population, which inflated the number of MDS patients and made the study findings difficult to interpret.

Validity of The Health Improvement Network (THIN) for epidemiologic studies of hepatitis C virus infection

Before using computerized databases to study hepatitis C virus (HCV) epidemiology, the validity of the diagnosis must be assessed. We determined the accuracy of HCV diagnostic codes within The Health Improvement Network (THIN), an electronic database containing medical record data from general medical practices in the United Kingdom. Patients with initial diagnostic codes for HCV infection and nonspecific viral hepatitis between 2000 and 2007 in the THIN database were identified. Questionnaires were mailed to general practitioners caring for a random sample of 150 of these patients (75 with an HCV code; 75 with a nonspecific viral hepatitis code) to collect information on HCV and other hepatitis diagnoses. We determined the positive predictive value of the database's HCV diagnostic codes and its ability to identify the date of a new HCV diagnosis. Usable surveys were returned for 146 (97%) patients. Among 74 patients with an HCV code and questionnaire data, HCV was confirmed in 64 (positive predictive value, 86%; 95%CI, 77-93%). In 40 (63%), the first recorded diagnosis in THIN was within 30 days of the date reported in the questionnaire (median difference, 11 days; interquartile range, 0-362 days). Among 72 patients with a nonspecific viral hepatitis code, 16 (22%) had HCV, but manual review of the database's electronic records correctly identified 12/16 (75%). In THIN, the HCV-specific diagnostic codes are highly predictive of HCV infection. After manual review, few patients with a nonspecific viral hepatitis code were misclassified as having HCV infection.

Development of a Computerized Medical History Profile for Children in Out-of-Home Placement Using Medicaid Data

Children in out-of-home placements (foster children) often undergo multiple placement changes while under the care of child protective services. This instability can result in lack of health care continuity and poor health outcomes. This brief describes the development of a medical history profile, or passport, developed from Medicaid administrative data. A purposive sample of 25 youths was provided from a county child protective services agency. The patients were systematically matched with data from the state Medicaid agency. Using Medicaid claims/encounter data we generated health care profiles that provided information on historical use of ambulatory care, diagnoses, providers seen, medications used, and inpatient admissions. However, profiles were limited by missing provider information and non-specific diagnostic coding. Despite these limitations, Medicaid data-based profiles show the potential to be a cost efficient method for improving continuity of care for children in out-of-home placement.

Cancer incidence in The Health Improvement Network

The utility of electronic medical record databases for clinical research relies on the validity and completeness of the recorded medical diagnoses. This study assessed whether the recorded incidence of cancer among patients in The Health Improvement Network (THIN) database is comparable to that expected in the UK based on national cancer registry data. We examined incidence rates of any cancer other than non-melanoma skin cancer and the specific cancers colorectal, lung, pancreas, and lymphoma from 1992 to 2007. Indirect standardization was used to calculate standardized incidence ratios (SIR) using age- and sex-specific rates from the UK cancer registry for England and Wales for the corresponding years. Recording of the incidence of all cancers combined in THIN was very close to the expected rates from 2001 to 2007, that is, SIR within 10% of unity. Recording of the solid cancers was less than the expected based on cancer registry data, but with SIRs > 0.80 in 2007 for each cancer. Recording of lymphoma was close to the expected rate for the entire follow-up period. Time and experience with Vision software emerged as important factors in reported incidence rates for all cancers. For all cancers combined and for lymphoma the observed rates in THIN are very close to those reported in cancer registry data for the years 2001-2007. However, for solid cancers the observed rates in THIN are below those reported in cancer registry data. This may reflect the use of non-specific codes to record solid cancers.

Do We Have Enough Information? How ICD-10-AM Activity Codes Measure UP

This research explored the usage of activity codes introduced into the International Statistical Classification of Diseases and Related Health Problems, Tenth revision, Australian Modification (ICD-10-AM) Third Edition and examined the data quality of activity coding, explicitly, completeness and specificity. Injury separations for years 2001/02 to 2005/06 specifying a 'true injury' were extracted for descriptive analyses. Part A investigated the usage of activity codes and compared the usage of the 236 activity codes available in the Activity block (U50-U73) present in the ICD-10-AM Third Edition against the 16 codes present in the second edition. Part B examined the level of completeness of external cause coding and the degree of activity coding specificity in the 2005/06 dataset. It was found that the additional activity codes were used extensively with only 46 codes seldom assigned. Codes present in the second edition were extensively used in the third and fourth editions and the new additional activity codes represent 10% of all activity codes assigned per year. All five datasets demonstrated high levels of completeness, recording completeness levels greater than 97%, where missing activity codes attributed to the majority of missing codes. Fourteen out of the 24 activity categories demonstrated a strong reliance on non-specific codes and Team ball sports and Wheeled non-motor sports illustrated that activity codes assigned lacked detail in the code. Clinicians and coders need to acknowledge the importance of quality clinical documentation for research and policy-making purposes so that circumstances surrounding injury events can be coded to the highest level of specificity to improve injury prevention and control activities. Missing activity codes and the abundance of non-specific coding hinders the usefulness of the data.

Survival from melanoma of the skin in England and Wales up to 2001.

Melanoma is unusual among tumours of adults in that it is generally defined by its morphology, not its anatomic location. Melanoma arises from melanocytes that are found mostly in the skin, but also in the bowel and the uveal and genital tracts. Only melanoma of the skin is considered here, including the very rare melanomas of the scrotal skin, defined both by anatomic location (ICD-9 1877, ICD-10 C632) and morphology. Melanoma of the skin has been increasing rapidly in the United Kingdom since the 1960s, as in many other countries (Coleman et al, 1993). Only prostate cancer rose more rapidly during the 1990s (Quinn et al, 2001). Almost 7000 cases are now diagnosed in England and Wales each year, almost double again the figure for 1990 (3700), itself double the number of cases in 1970. Melanoma now ranks as the sixth most frequent malignancy in women, accounting for 3% of tumours. The annual incidence rate in women (15 per 100 000) is higher than in men (12), and the risk is 2–3 times higher among the most affluent groups: both features are unusual for a malignancy. The increase in risk in England and Wales affects all ages, both sexes and all socioeconomic groups, although the rise has been more marked in the elderly, in women and in the most affluent (data not shown). Increases in mortality during the 1970s and 1980s were less marked than for incidence, and mortality trends slowed further during the 1990s, with a rise of only 8% in men and an actual fall of 12% in women. Stable or falling mortality alongside rapidly increasing incidence suggests substantial gains in survival. We report here the survival patterns for over 55 000 adults who were diagnosed with malignant melanoma of the skin in England and Wales during 1986–1999 and were followed up to 31 December 2001. They represent 92% of patients eligible for inclusion in the analyses. Some 2% of patients were excluded because their vital status was not known when the data were extracted for analysis on 2 November 2002, a further 3% because their duration of survival was zero or unknown, and another 3% because the melanoma was not their first invasive primary malignancy (data not shown). The skin of the leg and hip is still the most common location for a melanoma, but the distribution has shifted towards the trunk over the last 30 years. The leg and hip accounted for 45% of all melanomas in the early 1970s, but this figure has fallen steadily, reaching 32% by the late 1990s. The proportion arising on the skin of the trunk excluding the scrotum rose from 18 to 25% over the same period. The skin of the face, head and neck has accounted for a steady 15–16% throughout these three decades. Virtually all the tumours were assigned to one of the morphology codes for malignant melanoma, and only 2% had a nonspecific morphology code. As melanomas of the skin are primarily identified by an anatomic site code (ICD-9 172, ICD-10 C43), rather than their morphology, this suggests a high standard of diagnostic accuracy. The proportion of tumours coded as superficial spreading melanoma rose from 18% to 33% during the period 1986–1999, although the proportion classified simply as malignant melanoma fell from 70 to 56%. The annual number of melanomas has trebled since the early 1970s, so even this large proportional change does not adequately reflect the increase in superficial spreading melanoma, for which the number of cases in England and Wales almost doubled from 840 to 1500 cases a year between 1991 and 1999 alone (data not shown). This increase may well be real, and although it could also reflect a change in how pathologists describe and classify melanoma, a detailed review of melanoma incidence trends suggests a remarkable constancy in the pathological definition of melanoma over time and place, at least up to the late 1980s (van der Esch et al, 1991).

Evaluation of cause-of-death statistics for Brazil, 2002–2004

Mortality statistics systems with reliable cause-of-death data constitute a major resource for effective health planning; however, many developing countries lack such information systems. Brazil has a long history of registering deaths, and a critical assessment of the quality of current cause-of-death statistics in its five different regions is crucial to identify strengths and weaknesses in the data, and present options for improvement. Quality of cause-of-death data from 2002 to 2004 was evaluated using an assessment framework based on four main attributes: generalizability, reliability, validity and policy relevance. A set of nine criteria: coverage, completeness, consistency of cause patterns with general mortality levels, consistency of cause specific mortality proportions over time, content validity, proportion of ill-defined causes and non-specific codes, incorrect or improbable age or sex patterns, timeliness, and geographical disaggregation were used to assess the four attributes of data quality. Completeness of death registration varies from 72 to 80% in the northeast regions, compared with 85-90% in the Southeast and Centre-West regions, and 94-97% in the wealthier South region. The proportion of ill-defined deaths is an important problem in reported causes of death from almost all regions. Lack of adequate evidence limits the assessment of content validity of registered causes of death. Coverage, consistency of causes with general level of mortality, consistency over time, age and sex patterns, timeliness and usability of statistics for subnational purposes were judged to be reasonable and increase confidence in using the statistics. There is considerable heterogeneity in the quality of cause-of-death statistics across Brazilian regions, especially for criteria such as completeness and ill-defined causes. These factors can influence generalizability and validity of reported causes of death, and must be considered in the interpretation and use of data for secondary descriptive analyses such as burden of disease estimation at regional level, with suitable adjustments to account for bias. The differences identified in this study could be a useful guide for defining measures and investments needed to improve data quality in Brazil.