Primary ICD-9 Codes Research Articles

Diagnosis of Transient Ischemic Attack Varies by Neurologist (IN2-1.008)

Objective: The TIA-IS ratio, defined as the proportion of transient ischemic attack (TIA) among all TIA and ischemic stroke (IS) cases, varies between hospitals and between board-certified neurologists. Background The short duration of symptoms and multitude of non-vascular mimics make diagnosis of TIA subjective and challenging. Physician practice may influence whether a patient receives the diagnosis of TIA. Pathophysiology is the same for TIA and IS; therefore, the proportion of TIA versus IS should be the same across demographic and clinical strata and theoretically not vary between physicians. Design/Methods: Cases were identified using primary ICD9 discharge codes at three Montefiore hospitals, including a community hospital without neurology housestaff, from January 2009-June 2011. The TIA-IS ratio was determined for each hospital and for each board-certified neurologist with more than 25 TIA or IS discharges. Each TIA diagnosis was also confirmed by chart review, excluding cases with acute IS on brain imaging, duration >24 hours or a clearly non-vascular syndrome. Mantel-Hantsel chi-square was used for univariate statistical comparison. Results: There were 866 TIA and 2307 IS cases by primary ICD9 code, for an overall TIA-IS ratio of 27.3 %. The ratio was higher for the hospital lacking neurology housestaff (38.8%) versus the two hospitals with housestaff (25.5%, p Conclusions: The TIA-IS ratio differs between hospitals and varies widely among board-certified neurologists, with vascular neurologists less likely to diagnose TIA. The ABCD2 score, assessing symptoms and vascular risk factors, is promoted as a criterion for admission; however, these data suggest that physician training and perspective affect TIA diagnosis and thus assessment of future stroke risk. Disclosure: Dr. Bhupali has nothing to disclose. Dr. Sheikh has nothing to disclose. Dr. Labovitz has nothing to disclose.

Trends in Reasons for Hospitalization in a Multisite United States Cohort of Persons Living With HIV, 2001–2008

Hospitalization rates for comorbid conditions among persons living with HIV in the current highly active antiretroviral therapy era are unknown. Hospitalization data from 2001 to 2008 were obtained on 11,645 adults receiving longitudinal HIV care at 4 geographically diverse US HIV clinics within the HIV Research Network. Modified clinical classification software from the Agency for Healthcare Research and Quality assigned primary ICD-9 codes into diagnostic categories. Analysis was performed with repeated measures negative binomial regression. During 2001 to 2008, the rate of AIDS-defining illness (ADI) hospitalizations declined from 6.7 to 2.7 per 100 person-years, incidence rate ratio per year, 0.89 (0.87, 0.91). Among the other diagnostic categories with average rates >2 per 100 person-years, cardiovascular hospitalizations increased over time [1.07 (1.03, 1.11)], whereas non-AIDS-defining infection [0.98 (0.96, 1.00)], psychiatric [0.96 (0.93, 1.00)], and gastrointestinal/liver [0.96 (0.92, 1.00)] were slightly decreasing or stable. Although less frequent overall, renal and pulmonary admissions also increased over time in univariate and multivariate analyses. Of all diagnostic categories, ADI admissions had the longest mean length of stay, 10.5 days. ADI hospitalizations have continued to decline in recent years but are still relatively frequent and potentially costly given long lengths of stay. Increases or stability in the rates of chronic end-organ disease admissions imply a need for broader medical knowledge among individual clinicians and/or teams who care for persons living with HIV and a need for long-term access to medications for these conditions.

Abstract P333: Post-Stroke Outcomes Vary by Etiologic Stroke Subtype in the Atherosclerosis Risk in Communities Study

Background: Early risk of recurrent stroke and mortality after stroke differ by subtype, but less is known about long-term outcomes and all-cause hospital readmission. Understanding these differences may have implications for secondary prevention and treatment of stroke. We examined rates of recurrent stroke, all-cause hospital readmission, and mortality by index stroke etiologic subtype. Methods: Atherosclerosis Risk in Communities Study cohort participants with a definite/probable first-ever stroke were identified and followed until death or 12/31/2008. The association between index and recurrent stroke subtype and median times to first recurrent stroke and first hospital admission were assessed according to index stroke subtype (infarction: thrombotic, cardioembolic [CE], and lacunar; hemorrhagic: subarachnoid [SAH] and intraparenchymal [IPH]). Incidence rates of recurrent stroke, all-cause hospitalization, and death were calculated by index subtype. Reasons for hospitalization were identified using primary ICD-9 codes. Recurrent stroke outcomes for hemorrhagic subtypes are not reported here due to small numbers of events. Results: A total of 987 persons with first-ever stroke were identified and followed for an average 5.3±5.0 years post-stroke (48.7% thrombotic, 20.0% CE, 18.5% lacunar, 8.6% IPH, and 4.2% SAH). During follow-up, there were 183 recurrent strokes among 147 participants, 3234 hospitalizations among 746 participants, and 529 deaths. Only 139 (14.1%) participants had none of these events during follow up. Roughly 70% of recurrent strokes were of the same subtype as the index stroke; however, only a third were the same when the index stroke was lacunar. Time to first recurrent stroke varied by subtype (median days [range]; thrombotic, 930.5[2-4692]; CE, 271[2-5566]; lacunar, 789[5-4361]) while time to first hospitalization was more similar, ranging from 102.5[4-3634] among CE to 370[6-6506] among IPH. Incidence rates of recurrent stroke (per 100 person-years) were highest after lacunar stroke (4.4) followed by thrombotic (3.7), and CE (2.7). All-cause hospital readmission rates were: thrombotic (58.8), CE (88.9), lacunar (60.1), IPH (59.4), and SAH (35.3); and mortality rates were: thrombotic (9.0), CE (15.1), lacunar (7.4), IPH (22.3), and SAH (7.3). Non-stroke related hospitalizations, including heart failure, ischemic heart disease, and diabetes were not uncommon after stroke, particularly after thrombotic and CE strokes. Conclusion: While the highest mortality was observed for IPH, there was significant burden of recurrent stroke and all-cause hospitalization for other stroke subtypes, especially lacunar and CE. Hospital readmission rates were high for all subtypes, suggesting there may be opportunities to reduce post-stroke readmissions. Prevention efforts tailored according to etiologic stroke subtype may be warranted.

Abstract 3889: Diagnosis of Transient Ischemic Attack Varies by Neurologist

Introduction: The short duration of symptoms and multitude of non-vascular mimics make diagnosis of transient ischemic attack (TIA) subjective and challenging. Physician practice may influence whether a patient receives the diagnosis of TIA. Pathophysiology is the same for TIA and ischemic stroke (IS). Therefore, the proportion of TIA versus IS diagnoses should be the same across demographic and clinical strata and theoretically should not vary between physicians. Hypothesis: The TIA-IS ratio, defined as the proportion of TIA among all TIA and IS cases, varies between medicine and neurology services and between board-certified vascular and other neurologists. Methods: TIA and IS cases were identified using primary ICD9 discharge codes at Montefiore Medical Center from January 2009 through June 2011. Each TIA diagnosis was confirmed by chart review, excluding cases with acute IS on brain imaging, duration >24 hours or a clearly non-vascular syndrome. The TIA-IS ratio was assessed based on the primary ICD9 code and again on the diagnosis by chart review for discharges from the neurology versus the medicine service and also individually for each board-certified neurologist with more than 25 IS or TIA discharges during the study period. Mantel-Hantsel chi-square was used for univariate statistical comparison between groups. Results: There were 659 cases of TIA and 1927 cases of IS by primary ICD9 discharge code, for an overall TIA-IS ratio of 25.5 %. The ratio was higher for discharges from medicine (28.6%) than neurology services (23.8%, p=0.009). The ratio was higher for 12 non-vascular neurologists (27.0%, range 17.9-44.4%, 904 cases), than 5 vascular neurologists (20.0%, range 18.7-23.0, 715 cases, p=0.001). Chart review reduced the overall TIA-IS ratio to 16.3% and the difference between medicine and neurology discharges became non-significant but non-vascular neurologists still had a higher TIA-IS ratio (20.7%) than vascular neurologists (14.4%, p=0.001). Conclusions: The TIA-IS ratio is different on medicine and neurology services and varies widely among board-certified neurologists, with vascular neurologists less likely to assign the diagnosis of TIA than other neurologists even after excluding obvious non-TIA cases. The ABCD2 score, assessing patients’ symptoms and vascular risk factors, is promoted as a criterion for admission; however, these data suggest that physician training and perspective affect the diagnosis, and thus assessment of future stroke risk, as well.

School-Based Health Centers Are Critical In Addressing Health Disparities And Unmet Health Needs Of Oregon Adolescents

METHODS Encounter data collected at each clinic visit by adolescents attending Oregon SBHC during the 2001-2002 service year were analyzed using SPSS 15.0. There were a total of 17,700 patients aged 1119 years accounting for a total of 78,148 visits. Data included in these analyses were race/ ethnicity, age, gender, insurance status at fi rst visit, rural vs. urban location and primary ICD9 code for each of fi rst 10 visits. ICD-9 codes were grouped into the following diagnostic categories: Asthma Diabetes Health care maintenance Mental health Reproductive health Multivariate analyses were done using stepwise methods for both linear and logistic regression. Variables included in the multivariate equations were those statistically associated in univariate analyses. •

Mortality after an Emergency Department Visit for Exacerbation of Chronic Obstructive Pulmonary Disease

Objective. To describe the mortality after emergency department (ED) visits for chronic obstructive pulmonary disease (COPD) exacerbation. Design. Retrospective cohort study of ED patients with COPD exacerbation. Setting. Administrative data analysis. Participants. Patients age 55 and over who visited the ED during a 2-year period with primary ICD-9 codes of 491, 492, or 496. Measurements. Demographic characteristics, comorbid conditions, hospital utilization for COPD, and vital status. Results. During the study period, there were 482 index visits with a median follow-up of 1,1 28 days (3.1 years). Demographic characteristics of the cohort were as follows: mean age 72 years, 56% female, 93% White, and 37% currently married. Mortality increased over time: 5% at 30 days, 9% at 60 days, 11% at 90 days, 16% at 180 days, 23% at 1 year, 32% at 2 years, and 39% at 3 years. At the end of follow-up, 220 (46%) patients had died. On multivariate analysis, independent predictors of mortality were increasing age (hazard ratio [HR] 1.3 per 5-year increase, 95% CI 1.2–1.4), having congestive heart failure (HR 1.6, 95% CI 1.2–2.1), having metastatic solid tumor (HR 3.3, 95% CI 2.0–5.5), and hospital utilization for COPD exacerbation during past year (HR 1.9, 95% CI 1.4–2.6). Conclusion. The mortality rate after an ED visit for COPD exacerbation is quite high. Mortality is related to older age, specific comorbid conditions, and history of prior COPD exacerbations.

Implementation of an automated reporting system improves data collection on heart failure patients in a multi-hospital, integrated healthcare delivery system

Introduction: Incomplete data capture is an ongoing issue that can compromise the validity of quality improvement, quality assurance, and clinical studies. Intermountain Health Care, a 20-hospital integrated healthcare delivery system, treats over five thousand heart failure (HF) patients annually. A Discharge Medication Database (DMD) was instituted to track appropriate medication prescription and teaching for cardiac patients. To insure that all appropriate HF patients are identified and that pertinent data are entered into the DMD, we developed a weekly report specific to each facility. Hypothesis: The null hypothesis is that the implementation of this reporting system has no significant impact on the proportion of HF patient encounters with data in the DMD. Methods: The automated report utilizes a merged dataset from the Enterprise Data Warehouse. This dataset is derived from CaseMix data and the DMD. An electronic audit of the CaseMix data creates a table listing patient encounters with a primary diagnosis of heart failure and flags those encounters missing a record in the DMD. A standard reporting tool generates hospital-specific reports that are automatically emailed once a week. Discharge data are then retrospectively collected on the identified patient encounters and are entered into the system-wide database. From the three largest IHC hospitals, 1778 inpatient encounters with a primary ICD-9 code for heart failure and a discharge date between 2002 and 2003 were identified. Exclusionary criteria were aligned with JCAHO's Heart Failure Core Performance Measures. The primary outcome measurement was the proportion of eligible patient encounters entered into the DMD. Results: In 2002, 38.5 % of the HF patient encounters had data entered into the database. After implementation of the automated reporting system, the percentage had risen to 76.9% in 2003. This non-randomized binomial comparative study showed a significant (p=0.0043) increase in the proportion of HF patients with data in the DMD. Conclusions: Significant improvement in data collection can be achieved through the implementation of automated reporting systems. Successful systems require specific records to be identified and reported to the accountable persons in a timely manner.

How are TIAs managed in a managed care setting? Resource use and costs.

P193 This pilot study performed by members of the Greater Cincinnati / Northern Kentucky Stroke Team describes the retrospective examination of administrative claims data involving TIA survivors from a locally based managed care program. New TIA cases were identified between November 1997 and July 1998 and defined by an absence of a primary ICD9 code for a TIA or ischemic stroke during preceding 10–12 months. The managed care organization provided all inpatient hospital, outpatient hospital, ambulatory care and prescription claims for 12 months prior to and after the new case. Cases (n = 51) averaged 54.5 years of age and 56.9% were males. Predominant comorbidities included: hypertension (45.1%), and hypercholesterolemia (47.1%). Eight (15.7%) were hospitalized for their TIA. Total health care costs increased by only $568 from the period prior to the TIA. This limited increase in costs led us to question how these cases were evaluated and treated. We then compared the resources utilized to the AHA Stroke Council’s 1999 Supplement to Guidelines for the Management of Transient Ischemic Attacks and the 1997 AHA Practice Guidelines for Use of Imaging. This comparison was made to determine if these managed care enrollees received the recommended diagnostic evaluation and follow-up care directed towards the prevention of subsequent major cerebrovascular events. An analysis of the specific components of the managed care evaluation will be provided.

Resource use and costs of Ischemic Stroke in a Managed Care Setting

P200 Members of the Greater Cincinnati/Northern Kentucky Stroke Team retrospectively examined administrative claims data for a pilot study of 12-month survivors of acute ischemic stroke from a locally based managed care program. New ischemic stroke cases were identified between November 1997-July 1998 and defined by an absence of a primary ICD9 code for a TIA or ischemic stroke during the preceding 10–12 months. The managed care organization provided all inpatient hospital, outpatient hospital, ambulatory care and prescription claims for 12 months prior to and after the new case. Cases (n=54) averaged 56.1 years of age, 61.1% males and all survived the 1st year past stroke. Predominant comorbidities included: hypertension (50%), diabetes (24.1%), hypercholesterolemia (33.3%), ischemic heart disease (24.1%), and chronic respiratory illness (20.4%). Total health care costs increased by 244% from the period prior to the stroke. Stroke-related costs increased over 6-fold while non-stroke costs increased by 46%. We compared the resources utilized in the period after the ischemic stroke event to the AHA Stroke Council’s 1994 Guidelines for the Management of Acute Ischemic Stroke and 1997 AHA Practice Guidelines for Use of Imaging. This comparison was made to determine if the managed care enrollees received evaluations, treatments and services directed towards preventing recurrent strokes and maximizing patient outcome. An analysis of specific components of care delivered will be provided.

Resource use and costs of Ischemic Stroke in a Managed Care Setting

P200 Members of the Greater Cincinnati/Northern Kentucky Stroke Team retrospectively examined administrative claims data for a pilot study of 12-month survivors of acute ischemic stroke from a locally based managed care program. New ischemic stroke cases were identified between November 1997-July 1998 and defined by an absence of a primary ICD9 code for a TIA or ischemic stroke during the preceding 10–12 months. The managed care organization provided all inpatient hospital, outpatient hospital, ambulatory care and prescription claims for 12 months prior to and after the new case. Cases (n=54) averaged 56.1 years of age, 61.1% males and all survived the 1st year past stroke. Predominant comorbidities included: hypertension (50%), diabetes (24.1%), hypercholesterolemia (33.3%), ischemic heart disease (24.1%), and chronic respiratory illness (20.4%). Total health care costs increased by 244% from the period prior to the stroke. Stroke-related costs increased over 6-fold while non-stroke costs increased by 46%. We compared the resources utilized in the period after the ischemic stroke event to the AHA Stroke Council’s 1994 Guidelines for the Management of Acute Ischemic Stroke and 1997 AHA Practice Guidelines for Use of Imaging. This comparison was made to determine if the managed care enrollees received evaluations, treatments and services directed towards preventing recurrent strokes and maximizing patient outcome. An analysis of specific components of care delivered will be provided.

How are TIAs managed in a managed care setting? Resource use and costs.

P193 This pilot study performed by members of the Greater Cincinnati / Northern Kentucky Stroke Team describes the retrospective examination of administrative claims data involving TIA survivors from a locally based managed care program. New TIA cases were identified between November 1997 and July 1998 and defined by an absence of a primary ICD9 code for a TIA or ischemic stroke during preceding 10–12 months. The managed care organization provided all inpatient hospital, outpatient hospital, ambulatory care and prescription claims for 12 months prior to and after the new case. Cases (n = 51) averaged 54.5 years of age and 56.9% were males. Predominant comorbidities included: hypertension (45.1%), and hypercholesterolemia (47.1%). Eight (15.7%) were hospitalized for their TIA. Total health care costs increased by only $568 from the period prior to the TIA. This limited increase in costs led us to question how these cases were evaluated and treated. We then compared the resources utilized to the AHA Stroke Council’s 1999 Supplement to Guidelines for the Management of Transient Ischemic Attacks and the 1997 AHA Practice Guidelines for Use of Imaging. This comparison was made to determine if these managed care enrollees received the recommended diagnostic evaluation and follow-up care directed towards the prevention of subsequent major cerebrovascular events. An analysis of the specific components of the managed care evaluation will be provided.