Nonspecific Diagnosis Research Articles

Primary meningeal inflammatory pseudotumor

Inflammatory pseudotumors (IPs) encompass a wide spectrum of pathological entities of varying nomenclatures such as plasma cell granuloma, xanthomatous pseudotumor, and hypertrophic pachymeningitis. Majority of them are of uncertain etiology. Such tumor-mimicking lesions have been described in the lungs, liver, peritoneum, and retroperitoneal spaces. Primary convexity meningeal occurrence without intracerebral extension or extracranial presence is uncommon. We present one such rare case of a 50-year-old woman having a convexity primary meningeal IP with a 4-year follow-up post-excision. Radiology of IP may be nonspecific and pathological diagnosis is necessary in most cases to rule out meningeal neoplasms or infections, autoimmune/vasculitic, and other unusual mimics. Although surgical excision is warranted, complete resection may not be necessary if the frozen report is diagnostic. The differential diagnosis and treatment options are discussed further and a flowchart is provided depicting the meningeal tumor mimics.

Inpatient Diagnosis of Delirium and Encephalopathy: Coding Trends in 2011-2018

Physicians have long debated the diagnosis of acute confusional states as delirium or encephalopathy, often based on specialty. Recently, CMS assigned a lower severity to the nonspecific behavioral diagnosis of delirium than for the pathophysiological diagnosis of encephalopathy, potentially exacerbating these disagreements. Therefore, we sought to evaluate trends in these two diagnoses among hospitalized adults. Using 2011-2018 IBM MarketScan datasets, we identified delirium/encephalopathy patients who were ≥ 18 years and enrolled with medical and pharmacy coverage for each calendar year. Delirium/encephalopathy were defined using validated ICD-9/10 codes among hospitalized patients. We identified the physician specialties associated with the hospitalization and comorbidities using ICD9/10 inpatient/outpatient diagnosis codes within one year prior to the diagnosis of delirium or encephalopathy. Log-binomial models were used to evaluate the trends adjusting for age, gender, insurance and comorbidities. We identified 10,418 delirium and 87,393 encephalopathy hospitalized patients in 2011-2018. Of these patients, the total number of patients with either diagnosis increased, but the proportion of patients with delirium for each year decreased from 20% in 2011 to 9% in 2018. During the 8 years, neurologists and internists increased their use of both diagnoses, whereas psychiatrists only increased for delirium. Patients with encephalopathy are more likely to be older, female, and have more comorbidities. These shifts in diagnosis complicate the study of delirium and encephalopathy, and can lead to erroneous conclusions about trends in the incidence and prevalence of these disorders unless properly understood.

Diagnosis and Management of Subcoracoid Impingement.

Impingement of the subcoracoid space is a poorly understood pathologic cause of anterior shoulder pain. Because of its relative rarity in isolation and nonspecific presentation, diagnosis and management are often challenging for orthopaedic surgeons and their patients. Stenosis of the subcoracoid space between the lesser tuberosity and the coracoid process <6 mm can lead to anterior shoulder pain and associated rotator cuff and biceps pathology. Multiple imaging modalities are available to assess narrowing of the coracohumeral interval, each with its strengths and limitations. If the patient can be accurately diagnosed with subcoracoid impingement, both conservative and surgical management options are available. Despite earlier case series demonstrating promising results with arthroscopic treatment, comparative studies have yet to support these initial claims.

Lombalgie et grossesse

Low back pain in pregnant women most often involves a combination of pain in pelvic and lumbar region. It is a common problem for all women around the world. The causes of pain are unclear but concern probably a multitude of mechanical, hormonal, and vascular changes associated with pregnancy. On the other hand, risk factors of pain are better identified, with pain being more common in women with a history of low back pain, higher BMI and lack of physical activity. The majority of pain are non-specific low back pain and diagnosis consists in differentiating between spinal and non-spinal pain (sacroiliac joints, bone fissures…), eliminating red flags and neurological complications. Radiological prescriptions must be avoided and if needed, MRI would be preferred. The clinical course of low back pain is often favourable after delivery, but a small percentage of women describe recurrent or persistent pain after several years. Management is based on improvement of pain, staying active with the objectives of relieving pain and maintaining a good quality of life.

Influenza surveillance using family-reported outcomes at emergency triage in Southern Taiwan

Background: Pediatric infections are often non-specific and clinical diagnoses rely much on history taking from family. We applied Natural Language Processing (NLP) to evaluate family reported outcome and to develop a novel syndromic surveillance for influenza-like illness among pediatric patients. Methods and materials: Patients’ vital signs and family reported outcome from chief compliant at emergency triage were analyzed to extract nigh major syndrome groups of influenza-like illness: (1) fever, chills and sweating, (2) headache, cry and irritate, (3) nose, (4) mouth and throat, (5) eye, (6) ear, (7) skin rash, (8) gastrointestine (9) appetite and activity. Neural Network (a machine learning algorithm) was compared with domain expert keywords. The trends of the 9 syndrome groups were compared with clinical diagnoses at discharge among children visiting emergency department at a medical center in Taiwan, from Jan 2017 to Dec 2018. Results: During the two-year period, there were totally 29,233 events of pediatric emergency visits, and 15,414 (53%) were clinical diagnosed influenza-like illness (ICD-9: 460–488). Boys (56%) and young children were more dominant in respiratory infections: infant (16%), toddlers (48%), and preschooler (20%). The Pearson correlation between trend of clinical diagnosed respiratory infections and trend of body temperature ≥38 °C was 0.84. The correlation increased when using syndrome group (1) “fever, chills and sweating”, which achieved a higher correlation at 0.94, and the correlation further increased to 0.95 (p < 0.05) when combining syndrome groups (1) to (4). Conclusion: Patients’ vital signs and family reported outcome at initial encounter can be applied as an effective and timely syndromic surveillance to predict influenza-like illness at emergency department.

Influenza surveillance using family-reported outcomes at emergency triage in southern Taiwan

Background: Pediatric infections are often non-specific and clinical diagnoses rely much on history taking from family. We applied Natural Language Processing (NLP) to evaluate family reported outcome and to develop a novel syndromic surveillance for influenza-like illness among pediatric patients. Methods & materials: Patients’ vital signs and family reported outcome from chief compliant at emergency triage were analyzed to extract nigh major syndrome groups of influenza-like illness: (1) fever, chills and sweating, (2) headache, cry and irritate, (3) nose, (4) mouth and throat, (5) eye, (6) ear, (7) skin rash, (8) gastrointestine (9) appetite and activity. Neural Network (a machine learning algorithm) was compared with domain expert keywords. The trends of the 9 syndrome groups were compared with clinical diagnoses at discharge among children visiting emergency department at a medical center in Taiwan, from Jan 2017 to Dec 2018. Results: During the two-year period, there were totally 29,233 events of pediatric emergency visits, and 15,414 (53%) were clinical diagnosed influenza-like illness (ICD-9: 460–488). Boys (56%) and young children were more dominant in respiratory infections: infant (16%), toddlers (48%), and preschooler (20%). The Pearson correlation between trend of clinical diagnosed respiratory infections and trend of body temperature ≥ 38 °C was 0.84. The correlation increased when using syndrome group (1) “fever, chills and sweating”, which achieved a higher correlation at 0.94, and the correlation further increased to 0.95 (p < 0.05) when combining syndrome groups (1) to (4). Conclusion: Patients’ vital signs and family reported outcome at initial encounter can be applied as an effective and timely syndromic surveillance to predict influenza-like illness at emergency department.

Review of 189 Consecutive Female Genital Skin and Mucosal Biopsies Submitted to an Academic Dermatopathology Practice.

To describe consecutive vulvar biopsy cases and to create an educational template for pathology trainees and practicing pathologists. We reviewed 189 consecutive biopsies from the female genital area skin and mucosa. We classified them based on etiologies and examined limited clinical information. We classified diagnoses as squamous intraepithelial neoplasia (21.5%), melanocytic neoplasia (17.9%), lichenoid dermatoses (15.9%), nonlichenoid dermatoses (11.3%), infectious (6.2%), reparative (4.6%), or miscellaneous (22.6%). The miscellaneous diagnoses included common entities (polyps and cysts) and rarer entities (calcinosis cutis, adnexal neoplasms, or basal cell carcinoma) and nonspecific descriptive diagnoses. Clinicians most often included the actual diagnosis in their differential for melanocytic lesions (83%) and least often for inflammatory lesions (32%). However, some cases included a clinical description without a differential diagnosis (14%) or no helpful clinical information (4%). The distribution of whether correct diagnoses were included in the clinical differential was similar between submitting physicians and midlevel providers. Understanding squamous and melanocytic pathology and the various lichenoid and other inflammatory diagnoses is critical for signing out female genital tract skin pathology. The cases examined in this report can serve as an educational template for trainees and practicing pathologists.

Use of ICD-10 Codes for Identification of Injection Drug Use-Associated Infective Endocarditis Is Nonspecific and Obscures Critical Findings on Impact of Medications for Opioid Use Disorder.

BackgroundNo International Classification of Diseases, 10th revision (ICD-10), diagnosis code exists for injection drug use–associated infective endocarditis (IDU-IE). Instead, public health researchers regularly use combinations of nonspecific ICD-10 codes to identify IDU-IE; however, the accuracy of these codes has not been evaluated.MethodsWe compared commonly used ICD-10 diagnosis codes for IDU-IE with a prospectively collected patient cohort diagnosed with IDU-IE at Barnes-Jewish Hospital to determine the accuracy of ICD-10 diagnosis codes used in IDU-IE research.ResultsICD-10 diagnosis codes historically used to identify IDU-IE were inaccurate, missing 36.0% and misclassifying 56.4% of patients prospectively identified in this cohort. Use of these nonspecific ICD-10 diagnosis codes resulted in substantial biases against the benefit of medications for opioid use disorder (MOUD) with relation to both AMA discharge and all-cause mortality. Specifically, when data from all patients with ICD-10 code combinations suggestive of IDU-IE were used, MOUD was associated with an increased risk of AMA discharge (relative risk [RR], 1.12; 95% CI, 0.48–2.64). In contrast, when only patients confirmed by chart review as having IDU-IE were analyzed, MOUD was protective (RR, 0.49; 95% CI, 0.19–1.22). Use of MOUD was associated with a protective effect in time to all-cause mortality in Kaplan-Meier analysis only when confirmed IDU-IE cases were analyzed (P = .007).ConclusionsStudies using nonspecific ICD-10 diagnosis codes for IDU-IE should be interpreted with caution. In the setting of an ongoing overdose crisis and a syndemic of infectious complications, a specific ICD-10 diagnosis code for IDU-IE is urgently needed.

ALL-045: Community-Acquired Viral Infections in Hospitalized Egyptian Children with Malignancy

Context Children with cancer comprise an important immunocompromised population who are more vulnerable and at high-risk to a variety of infectious pathogens, including respiratory viruses that are widespread in the community. Objective Studying the role of these viruses is important especially in countries with high population density, increasing chances of community-acquired infections. This prospective study aimed to assess the annual prevalence of community-acquired respiratory viral infections among children with cancer presenting with clinical picture suggestive of lower respiratory tract infections (LRTIs), and evaluate its risk factors and prognosis. Design Patients who presented either to the out-patient clinic or to the emergency department, had clinical evidence and/or radiological criteria suggestive of LRTIs, and were fulfilling the criteria of community-acquired infection were recruited, subjected to clinical assessment, investigated through hematology panel, blood culture, chest X-ray, CT chest, and PCR for influenza A and B, parainfluenza (PIV) types 1 and 3 viruses, and respiratory syncytial virus (RSV), and prospectively followed up for the clinical outcome. Results Over a year, 90 eligible children were recruited; 48 patients had ALL, 9 had AML, and 33 had solid tumors; 54.4% of them were in the induction phase. Annual prevalence of viral infections was 37.7%, with a seasonal peak from April to May. The most frequently detected virus was influenza virus [type A (47%), type B (12%)] followed by parainfluenza virus [PIV1 (26%), PIV3 (15%)], and none had RSV. Bacteria were identified in 26 patients, fungi in four, mixed infections (bacterial/viral and bacterial/fungal) in 13, and 36 cases had unidentified etiology. The majority of patients with influenza and parainfluenza infections had haematological malignancy, presented with fever, and had mild self-limited respiratory illness. Five patients with mixed viral and bacterial infection had severe symptoms, necessitating ICU admission. Six patients died from infection-related sequelae; two had mixed PIV and staphylococcal infections. Conclusions Community-acquired influenza and parainfluenza infections are common in pediatrics children with malignancy, either as isolated or mixed viral/bacterial infections. Clinical suspicion is essential as radiological manifestations are non-specific and mandate rapid diagnosis and management to improve patients' outcome.

Where are we moving in the classification of idiopathic inflammatory myopathies?

Discoveries of myositis-specific antibodies, transcriptomic signatures, and clinicoseropathological correlation support classification of idiopathic inflammatory myopathies (IIM) into four major subgroups: dermatomyositis, immune-mediated necrotizing myopathy (IMNM), antisynthetase syndrome (ASS), and inclusion body myositis (IBM) whereas leaving polymyositis as a historical nonspecific diagnosis of exclusion. This review summarizes and comments on recent knowledge regarding the major subgroup of IIM. Type 1 interferon (IFN1) pathway activation is the most prominent in dermatomyositis whereas type 2 interferon (IFN2) pathway activation is high in IBM and ASS; neither pathway is distinct in IMNM. Myxovirus-resistant protein A, IFN1 surrogate marker, is now one of definite dermatomyositis muscle biopsy criteria in the new 2018 European Neuromuscular Centre classification of dermatomyositis; the classification emphasizes on different categorization with and without dermatomyositis-specific antibody result. Novel HLA loci associated with anti-TIF1-γ, anti-Mi-2, and anti-Jo-1 antibodies in Caucasian population are identified. Associations of chaperon-assisted selective autophagy (CASA) and complement-mediated autoimmunity in IMNM as well as highly differentiated T cells in IBM are discovered. Current IIM classification requires integrated clinicoseropathological approaches. Additional information, such as transcriptomics, HLA haplotyping, and potential biomarkers help tailoring categorization that may have future diagnostic and therapeutic implications.

Determining the incidence of needle-related complications in hemodialysis access: We need a better system.

Hemodialysis access complications are common. We hypothesize that many of these complications can be traced back to needle-related injury from routine cannulation practices or inadvertent cannulation injuries. We set out to compare the rates of hemodialysis access complications under prior and current diagnosis coding systems, determine the incidence of needle-related complications for hemodialysis access, and describe the association of needle-related complications and resulting interventions. Arteriovenous graft and arteriovenous fistula placements occurring in the first 6 months of 2014 and 2016 were identified in the United States Renal Data System Medicare claims data. Placements were followed until end of hemodialysis access life or end of the calendar year. Diagnoses and resulting interventions occurring during placement life were identified and mapped to needle-related complication terms. Almost 30,000 placements for 27,000 patients were followed in each year, with 67% of all accesses placed being arteriovenous fistula and 33% arteriovenous graft. In both years, 75% of arteriovenous fistulae and arteriovenous grafts required one or more interventions. Stenosis and thrombosis were the most common complications diagnosed and treated (41% and 16%, respectively); however, potential needle-related complications accounted for 6% of this dataset. International Classification of Diseases, 9th Revision, was inadequate for determining the incidence of specific hemodialysis access complications or needle-related complications. International Classification of Diseases, 10th Revision, introduced several more hemodialysis access diagnoses but is still subject to coding confusion and catch-all coding for a variety of common and otherwise well-defined complications, suggesting that the true incidence of needle-related complications is buried in the non-specific diagnosis codes. These findings mark the clear need for an improved diagnosis coding system that consistently represents all common hemodialysis access complications.

THE APPLICATION OF LUNG MRI IN CASES OF COVID-19 INFECTION

A new coronavirus infection (COVID-19), which epidemic affected almost all states at the beginning of 2020, is also diagnosed radiologically, including computed tomography (CT), which is considered to be the gold standard for this. The lack of awareness among doctors and patients in a number of regions of Russia about the radiology use, need and appropriateness in this infection has led to unreasonable, overly frequent prescribing of chest CT by clinicians, as well as an increase in the chest CT ordering at the urgent request of the patients themselves, despite attempts of radiologists to convince those and others that, most often, this technique is not needed, as not affecting the observation and treatment strategy. The overload of CT units resulting from this has led to its limited availability, which, in addition, can also occur when CT devices get out of order. This publication is dedicated to our experience with magnetic resonance imaging (MRI) for the diagnosis of viral pneumonia. Changes detected on MRI are similar to those visible on CT, it is possible to detect a sign of «ground glass opacity», consolidations, reverse halo sign, fluid in the pleural cavity, air bronchography with an accuracy not less than that of CT, especially if the size of the pathological changes exceeds 1 cm. In addition, MRI allows the differential diagnosis of viral pneumonia and other clinical situations able to simulate it, such as a bron chogenic tumors with retro obstructive pneumonitis, exudative pleurisy, bacterial pneumonia, and bacterial infection inside the viral pneumonia. Given the inaccessibility of CT and/or radiation exposure conserns, MRI can serve as a fairly reliable alternative method for viral pneumonia and other pathological conditions with a nonspecific clinical picture radiological diagnosis and differential diagnosis, provided that anti-epidemic measures are observed and there are no absolute contraindications for MRI.

Non-specific diagnoses are frequent in patients hospitalized after calling 112 and their mortality is high \u2013 a register-based Danish cohort study

BackgroundThe number of patients calling for an ambulance increases. A considerable number of patients receive a non-specific diagnosis at discharge from the hospital, and this could imply less serious acute conditions, but the mortality has only scarcely been studied. The aim of this study was to examine the most frequent sub-diagnoses among patients with hospital non-specific diagnoses after calling 112 and their subsequent mortality.MethodsA historical cohort study of patients brought to the hospital by ambulance after calling 112 in 2007–2014 and diagnosed with a non-specific diagnosis, chapter R or Z, in the International Classification of Diseases, 10th edition (ICD-10). 1-day and 30-day mortality was analyzed by survival analyses and compared by the log-rank test.ResultsWe included 74,847 ambulance runs in 53,937 unique individuals. The most frequent diagnoses were ‘unspecified disease’ (Z039), constituting 47.0% (n 35,279). In children 0–9 years old, ‘febrile convulsions’ was the most frequent non-specific diagnosis used in 54.3% (n 1602). Overall, 1- and 30-day mortality was 2.2% (n 1205) and 6.0% (n 3258). The highest mortality was in the diagnostic group ‘suspected cardiovascular disease’ (Z035) and ‘unspecified disease’ (Z039) with 1-day mortality 2.6% (n 43) and 2.4% (n 589), and 30 day mortality of 6.32% (n 104) and 8.1% (n 1975).ConclusionAmong patients calling an ambulance and discharged with non-specific diagnoses the 1- and 30-day mortality, despite modest mortality percentages lead to a high number of deaths.

Increased Costs and Health Care Utilization Associated with Delay in Diagnosis of ACL Injuries

Objectives:Anterior cruciate ligament (ACL) injuries can be difficult to diagnose, especially among providers with limited musculoskeletal training. Early and accurate diagnosis of ACL injuries is important for initiating proper treatment and limiting inefficient or costly healthcare utilization. We hypothesized that a delayed diagnosis in patients sustaining ACL injuries would result in treatment that is more costly and utilizes more healthcare resource compared to patients diagnosed without delay.Methods:A large national private insurance database (Truven MarketScan) was utilized to identify all patients aged 10-63 years-old diagnosed with an ACL tear from 2011 through 2015. Patients with a possible delay in diagnosis were determined via a database search for the most commonly assigned alternative knee-related diagnosis codes found in patients who were later diagnosed with an ACL tear. Patients were stratified into three groups according to time from non-specific knee diagnosis code to ACL diagnosis: 1) no delay (0 days), short delay (1-30 days) and long delay (>30 days). Subsequent cost and healthcare utilization data including physical therapy, medication use, and number of clinic visits were collected for a period of one-year after initial presentation with an ACL tear or knee-related diagnosis.Results:A search from 2011 through 2015 identified 87,435 patients meeting inclusion criteria that were diagnosed with an ACL injury. There were 24.1% of patients diagnosed at initial presentation whereas 43.5% were diagnosed between one day and 30 days. There were 38.2% of patients that were treated without surgery and had the lowest total cost regardless of delay in diagnosis (Table 1). ACL reconstruction combined with other knee procedures had the highest total cost, particularly with a longer delay in diagnosis. Each day of delay in diagnosis was three times more costly in the non-surgical (additional $27.06 cost per day of delay) versus the surgical groups ($8.09 cost per day of delay).Conclusions:A timely diagnosis of ACL injuries is associated with a lower cost of treatment and less visits to healthcare providers. Non-operative injuries may benefit the most from a timely diagnosis given the high additional cost per day of diagnosis delay. In order to further decrease the burden on the healthcare system, future studies should assess methods than can decrease delays in diagnosis while measuring cost and utilization differences as well as outcomes after ACL tears.

Use of Statewide Administrative Data to Assess Clinical Outcomes: A Retrospective Cohort Study of Therapeutic Anticoagulation for Isolated Calf Vein Thrombosis.

Single-center comparative effectiveness studies evaluating outcomes that can occur posthospitalization may become biased if outcomes diagnosed at other facilities are not ascertained. Administrative datasets that link patients' records across facilities may improve outcome ascertainment. To determine whether use of linked administrative data significantly augments thromboembolic outcome ascertainment. Retrospective cohort study. Patients with an acute isolated calf deep vein thrombosis (DVT) diagnosed at 1 Californian center during 2010-2013. Proximal DVT or pulmonary embolism (PE) within 180 days. We ascertained outcomes from linked California hospitalization, emergency department, and ambulatory surgery data and compared this information to outcomes previously identified from review of the center's medical records. Among 384 patients with an isolated calf DVT, 333 could be linked to longitudinal administrative data records. Ten patients had a possible proximal DVT or PE (4 more clearly so) from administrative data; all were unknown from medical record review. Eleven patients with known outcomes from medical record review had no outcome from administrative data. The adjusted odds ratio of proximal DVT or PE with therapeutic anticoagulation attenuated from 0.33 [95% confidence interval (CI), 0.12-0.87] using only medical record review to 0.64 (95% CI, 0.29-1.40) using both medical record review and possible outcomes from administrative data. Restricting the outcome to diagnoses clearly involving proximal DVT or PE, the adjusted odds ratio was 0.46 (95% CI, 0.19-1.10). Use of linked hospital administrative data augmented detection of outcomes but imperfect linkage, nonspecific diagnoses, and documentation/coding errors introduced uncertainty regarding the accuracy of outcome ascertainment.

Most Orthopaedic Studies Using the National Inpatient Sample Fail to Adhere to Recommended Research Practices: A Systematic Review.

The National Inpatient Sample (NIS) database is accessible, inexpensive, and increasingly used in orthopaedic research, but it has complex design features that require nuanced methodological considerations for appropriate use and interpretation. A recent study showed poor adherence to recommended research practices for the NIS across a broad spectrum of medical and surgical fields, but the degree and patterns of nonadherence among orthopaedic publications remain unclear. In this study, we sought: (1) to quantify nonadherence to recommended research practices provided by the Agency for Healthcare Research and Quality (AHRQ) for using the NIS data in orthopaedic studies from 2016-2017; and, (2) to identify the most common nonadherence practices. We evaluated all 136 manuscripts published across the 74 orthopaedic journals listed on Scimago Journal & Country Rank that used the NIS from January 2016 through December 2017. Of those studies, 2% (3 of 136) were excluded because NIS was not used for analysis. The studies were evaluated for adherence to seven recommended research practices by the AHRQ: (1) identifying observations as hospitalization events rather than unique patients; (2) not performing state-level analyses; (3) limiting hospital-level analyses to data from year 1988-2011; (4) not performing physician-level analyses; (5) avoiding the use of nonspecific secondary diagnosis codes to infer in-hospital events; (6) using survey-specific analysis methods that account for clustering, stratification, and weighting; and (7) accounting for data changes in trend analyses spanning major transition periods in the data set (1997-1998 and 2011-2012). Overall, 93% (124 of 133) of the studies did not adhere to one or more practices. For each of the research practices assessed, 80% (106 of 133) of the studies did not account for the clustering and stratification in survey design; 56% (75 of 133) implied records were unique patients rather than hospitalization events; 41% (54 of 133) inappropriately used secondary diagnosis codes to infer in-hospital events. Nearly all manuscripts published in orthopaedic journals using the NIS database in 2016 and 2017 failed to adhere to recommended research practices. Future research quantifying variations in study results on the basis of adherence to recommended research practices would be of value. With the ubiquitous presence of large-database studies in orthopaedic journals, our work points to the importance of rigorous methodological appraisal when evaluating results, and encourages journals to require the use of the methodology checklists upon submission of such studies. More research is needed to determine whether deviations from recommended research practices actually lead to biased conclusions that affect patient care and policy-related decisions.

4486 Assessing the Validity of an ICD-9 and ICD-10 Coding Algorithm for Identifying Cervical Premalignant Lesions Using Administrative Claims Data

OBJECTIVES/GOALS: We compared the validity of an International Classification of Diseases, Clinical Modification (ICD) algorithm for identifying high-grade cervical intraepithelial neoplasia and adenocarcinoma in situ (together referred to as CIN2+) from ICD 9th revision (ICD-9) and 10th revision (ICD-10) codes. METHODS/STUDY POPULATION: Using Tennessee Medicaid data, we identified cervical diagnostic procedures in 2008-2017 among females aged 18-39 years in Davidson County, TN. Gold-standard cases were pathology-confirmed CIN2+ diagnoses validated by HPV-IMPACT, a population-based surveillance project in catchment areas of five US states. Procedures in the ICD transition year (2015) were excluded to account for implementation lag. We pre-grouped diagnosis and procedure codes by theme. We performed feature selection using least absolute shrinkage and selection operator (LASSO) logistic regression with 10-fold cross validation and validated models by ICD-9 era (2008-2014, N = 6594) and ICD-10 era (2016-2017, N = 1270). RESULTS/ANTICIPATED RESULTS: Of 7864 cervical diagnostic procedures, 880 (11%) were true CIN2+ cases. LASSO logistic regression selected the strongest features of case status: Having codes for a CIN2+ tissue diagnosis, non-specific CIN tissue diagnosis, high-grade squamous intraepithelial lesion, receiving a cervical treatment procedure, and receiving a cervical/vaginal biopsy. Features of non-case status were codes for a CIN1 tissue diagnosis, Pap test, and HPV DNA test. The ICD-9 vs ICD-10 algorithms predicted case status with 68% vs 63% sensitivity, 95% vs 94% specificity, 63% vs 64% positive predictive value, 96% vs 94% negative predictive value, 92% vs 89% accuracy, and C-indices of 0.95 vs 0.92, respectively. DISCUSSION/SIGNIFICANCE OF IMPACT: Overall, the algorithm’s validity for identifying CIN2+ case status was similar between coding versions. ICD-9 had slightly better discriminative ability. Results support a prior study concluding that ICD-10 implementation has not substantially improved the quality of administrative data from ICD-9.

Association of Traumatic Brain Injury With Vestibular Dysfunction and Dizziness in Post-9/11 Veterans.

To describe the prevalence and impact of vestibular dysfunction and nonspecific dizziness diagnoses and explore their associations with traumatic brain injury (TBI) severity, mechanism, and postconcussive comorbidities among post-9/11 veterans. Administrative medical record data from the US Departments of Defense and Veterans Affairs (VA). Post-9/11 veterans with at least 3 years of VA care. Cross-sectional, retrospective, observational study. International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes for TBI, vestibular dysfunction, dizziness, and other commonly associated postconcussive conditions; Neurobehavioral Symptom Inventory. Of the 570 248 post-9/11 veterans in this sample, 0.45% had a diagnosis of vestibular dysfunction and 2.57% had nonspecific dizziness. Those with either condition were more likely to have evidence of TBI (57.11% vs 28.51%) and reported more disruption from neurobehavioral symptoms. Blast and nonblast injuries were associated with greater symptom disruption, particularly in combination. There was a consistent, significant association between TBI and vestibular dysfunction or nonspecific dizziness, after controlling for sociodemographic factors, injury mechanism, and comorbid conditions. Given that most deployed post-9/11 veterans report blast and/or nonblast injuries, the need for prompt identification and management of these conditions and symptoms is clear.

Complex care pathways for children with multiple referrals demonstrated in a retrospective population-based study.

To identify children with complex medical needs by examining their patterns of hospital care. We conducted a retrospective population-based study on 18577 patients aged 6-12years from the Haukeland University Hospital register over a 3-year period (from 2013 to 2015). Data were structured to examine the temporal patterns and sequences of referrals, care episodes and diagnoses, including flowacross medical specialties. Over a third of patients had repeated referrals, and 14.9% of all had three or more. Furthermore, 9.3% of patients were referred to both somatic and mental healthcare services. Patients with such combined referrals had a higher number of referrals as well as a higher number of different diagnoses. Overall, there was a high frequency of non-specific diagnoses, and 34.8% of patients still had a non-specific main diagnosis at the end of their hospital contact. This study demonstrates an increased risk for complex care pathways in children with multiple referrals. Interdisciplinary patterns of referrals were relatively common, particularly for patients in mental health care. These findings highlight the importance of developing interdisciplinary-based approaches for patients with complex complaints.

Acute care pathways for patients calling the out-of-hours services

BackgroundIn Western countries, patients with acute illness or injury out-of-hours (OOH) can call either emergency medical services (EMS) for emergencies or primary care services (OOH-PC) in less urgent situations. Callers initially choose which service to contact; whether this choice reflect the intended differences in urgency and severity is unknown. Hospital diagnoses and admission rates following an OOH service contact could elucidate this. We aimed to investigate and compare the prevalence of patient contacts, subsequent hospital contacts, and the age-related pattern of hospital diagnoses following an out-of-hours contact to EMS or OOH-PC services in Denmark.MethodsPopulation-based observational cohort study including patients from two Danish regions with contact to EMS or OOH-PC in 2016. Hospital contacts were defined as short (< 24 h) or admissions (≥24 h) on the date of OOH service contact. Both regions have EMS, whereas the North Denmark Region has a general practitioner cooperative (GPC) as OOH-PC service and the Capital Region of Copenhagen the Medical Helpline 1813 (MH-1813), together representing all Danish OOH service types. Calling an OOH service is mandatory prior to a hospital contact outside office hours.ResultsOOH-PC handled 91% (1,107,297) of all contacts (1,219,963). Subsequent hospital contacts were most frequent for EMS contacts (46–54%) followed by MH-1813 (41%) and GPC contacts (9%). EMS had more admissions (52–56%) than OOH-PC. For both EMS and OOH-PC, short hospital contacts often concerned injuries (32–63%) and non-specific diagnoses (20–45%). The proportion of circulatory disease was almost twice as large following EMS (13–17%) compared to OOH-PC (7–9%) in admitted patients, whereas respiratory diseases (11–14%), injuries (15–22%) and non-specific symptoms (22–29%) were more equally distributed. Generally, admitted patients were older.ConclusionsEMS contacts were fewer, but with a higher percentage of hospital contacts, admissions and prevalence of circulatory diseases compared to OOH-PC, perhaps indicating that patients more often contact EMS in case of severe disease. However, hospital diagnoses only elucidate severity of diseases to some extent, and other measures of severity could be considered in future studies. Moreover, the socio-demographic pattern of patients calling OOH needs exploration as this may play an important role in choice of entrance.