Abrams Thad E, Vaughan-Sarrazin Mary, Rosenthal Gary E
Department of Internal Medicine, University of Iowa, Center for Research in the Implementation of Innovative Strategies in Practice, Iowa City VA Healthcare System, Iowa City, Iowa, USA.
Circ Cardiovasc Qual Outcomes. 2009 May;2(3):213-20. doi: 10.1161/CIRCOUTCOMES.108.829143. Epub 2009 Apr 28.
Prior studies of the impact of psychiatric comorbidity on outcomes after acute myocardial infarction (AMI) have frequently relied on inpatient secondary diagnosis codes. This study compared associations between psychiatric comorbidity and AMI outcomes that were derived using secondary diagnosis codes and codes captured from prior outpatient encounters.
Retrospective cohort study analyzing 21 745 patients admitted in 2004 to 2006 to Veterans Health Administration hospitals with AMI using administrative data. Psychiatric comorbidity was identified using (1) secondary inpatient diagnosis codes from the index hospitalization and (2) diagnoses from prior outpatient encounters. Outcomes included 30- and 365-day mortality and the receipt of coronary revascularization within 30 days of admission. Generalized estimating equations and Cox proportional hazards were used to adjust mortality and receipt of revascularization for demographic and clinical variables. Psychiatric disorders were identified in 2285 (10%) patients from inpatient secondary diagnosis codes and 5225 (24%) patients from prior outpatient codes. Patients with psychiatric comorbidity had higher adjusted 30- and 365-day mortality, based on outpatient codes (odds ratios, 1.19 [95% CI, 1.09 to 1.30] and 1.12 [95% CI, 1.03 to 1.22], respectively), but similar mortality based on inpatient codes (odds ratios, 0.89 [95% CI, 0.69 to 1.01] and 0.93 [95% CI, 0.82 to 1.06], respectively). In contrast, patients with psychiatric comorbidity had lower receipt of coronary revascularization based on outpatient codes (hazard ratio, 0.92; [95% CI, 0.85 to 0.99], but similar receipt based on inpatient codes (hazard ratio, 1.00 [95% CI, 0.91 to 1.10]).
Inpatient secondary diagnosis codes identified fewer patients with psychiatric comorbidity than prior outpatient codes. Moreover, associations with AMI outcomes differed for the 2 approaches. These findings raise potential concerns about the validity and reliability of psychiatric inpatient secondary diagnosis in estimating the impact of psychiatric comorbidities on AMI outcomes and in developing risk-adjustment models.
先前关于精神疾病合并症对急性心肌梗死（AMI）后预后影响的研究常常依赖住院患者的二级诊断编码。本研究比较了使用二级诊断编码以及从先前门诊就诊记录中获取的编码得出的精神疾病合并症与AMI预后之间的关联。
一项回顾性队列研究，利用管理数据对2004年至2006年因AMI入住退伍军人健康管理局医院的21745例患者进行分析。使用（1）本次住院的二级住院诊断编码和（2）先前门诊就诊的诊断来确定精神疾病合并症。结局包括30天和365天死亡率以及入院后30天内接受冠状动脉血运重建术的情况。使用广义估计方程和Cox比例风险模型对死亡率和血运重建术的接受情况进行人口统计学和临床变量的调整。根据住院患者二级诊断编码，在2285例（10%）患者中识别出精神疾病，根据先前门诊编码，在5225例（24%）患者中识别出精神疾病。基于门诊编码，有精神疾病合并症的患者调整后的30天和365天死亡率更高（比值比分别为1.19[95%CI，1.09至1.30]和1.12[95%CI，1.03至1.22]），但基于住院编码的死亡率相似（比值比分别为0.89[95%CI，0.69至1.01]和0.93[95%CI，0.82至1.06]）。相比之下，基于门诊编码，有精神疾病合并症的患者接受冠状动脉血运重建术的比例较低（风险比为0.92；[95%CI，0.85至0.99]），但基于住院编码的接受比例相似（风险比为1.00[95%CI，0.91至1.10]）。
住院患者二级诊断编码识别出的有精神疾病合并症的患者比先前门诊编码识别出的患者少。此外，两种方法与AMI结局的关联有所不同。这些发现引发了对精神科住院患者二级诊断在评估精神疾病合并症对AMI结局的影响以及开发风险调整模型方面的有效性和可靠性的潜在担忧。
