Departments of Neurological Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA.
J Neurosurg Spine. 2011 Jan;14(1):16-22. doi: 10.3171/2010.9.SPINE10151. Epub 2010 Dec 10.
large studies of ICD-9-based complication and hospital-acquired condition (HAC) chart reviews have not been validated through a comparison with prospective assessments of perioperative adverse event occurrence. Retrospective chart review, while generally assumed to underreport complication occurrence, has not been subjected to prospective study. It is unclear whether ICD-9-based population studies are more accurate than retrospective reviews or are perhaps equally susceptible to bias. To determine the validity of an ICD-9-based assessment of perioperative complications, the authors compared a prospective independent evaluation of such complications with ICD-9-based HAC data in a cohort of patients who underwent spine surgery. For further comparison, a separate retrospective review of the same cohort of patients was completed as well.
a prospective assessment of complications in spine surgery over a 6-month period (May to December 2008) was completed using an independent auditor and a validated definition of perioperative complications. The auditor maintained a prospective database, which included complications occurring in the initial 30 days after surgery. All medical adverse events were included in the assessment. All patients undergoing spine surgery during the study period were eligible for inclusion; the only exclusionary criterion used was the availability of the auditor for patient assessment. From the overall patient database, 100 patients were randomly extracted for further review; in these patients ICD-9-based HAC data were obtained from coder data. Separately, a retrospective assessment of complication incidence was completed using chart and electronic medical record review. The same definition of perioperative adverse events and the inclusion of medical adverse events were applied in the prospective, ICD-9-based, and retrospective assessments.
ninety-two patients had adequate records for the ICD-9 assessment, whereas 98 patients had adequate chart information for retrospective review. The overall complication incidence among the groups was similar (major complications: ICD-9 17.4%, retrospective 19.4%, and prospective 22.4%; minor complications: ICD-9 43.8%, retrospective 31.6%, and prospective 42.9%). However, the ICD-9-based assessment included many minor medical events not deemed complications by the auditor. Rates of specific complications were consistently underreported in both the ICD-9 and the retrospective assessments. The ICD-9 assessment underreported infection, the need for reoperation, deep wound infection, deep venous thrombosis, and new neurological deficits (p = 0.003, p < 0.0001, p < 0.0001, p = 0.0025, and p = 0.04, respectively). The retrospective review underestimated incidences of infection, the need for revision, and deep wound infection (p < 0.0001 for each). Only in the capture of new cardiac events was ICD-9-based reporting more accurate than prospective data accrual (p = 0.04). The most sensitive measure for the appreciation of complication occurrence was the prospective review, followed by the ICD-9-based assessment (p = 0.05).
an ICD-9-based coding of perioperative adverse events and major complications in a cohort of spine surgery patients revealed an overall complication incidence similar to that in a prospectively executed measure. In contrast, a retrospective review underestimated complication incidence. The ICD-9-based review captured many medical events of limited clinical import, inflating the overall incidence of adverse events demonstrated by this approach. In multiple categories of major, clinically significant perioperative complications, ICD-9-based and retrospective assessments significantly underestimated complication incidence. These findings illustrate a significant potential weakness and source of inaccuracy in the use of population-based ICD-9 and retrospective complication recording.
基于 ICD-9 的并发症和医院获得性疾病（HAC）图表回顾的大型研究尚未通过与围手术期不良事件发生的前瞻性评估进行比较来验证。虽然回顾性图表审查通常被认为会低估并发症的发生，但尚未对其进行前瞻性研究。目前尚不清楚基于 ICD-9 的人群研究是否比回顾性审查更准确，或者是否同样容易受到偏差的影响。为了确定基于 ICD-9 的围手术期并发症评估的有效性，作者将前瞻性评估与接受脊柱手术患者的 HAC 数据进行了比较。为了进一步比较，还完成了同一患者队列的单独回顾性审查。
使用独立审核员和围手术期并发症的验证定义，在 6 个月（2008 年 5 月至 12 月）期间完成了脊柱手术的并发症前瞻性评估。审核员维护了一个包含术后 30 天内发生的并发症的前瞻性数据库。评估包括所有医疗不良事件。所有接受脊柱手术的患者均有资格入选；唯一使用的排除标准是审核员是否有时间对患者进行评估。从总体患者数据库中随机抽取了 100 名患者进行进一步审查；在这些患者中，从编码员的数据中获得了基于 ICD-9 的 HAC 数据。另外，使用图表和电子病历回顾完成了并发症发生率的回顾性评估。在前瞻性、基于 ICD-9 的和回顾性评估中应用了相同的围手术期不良事件定义和包括医疗不良事件。
92 名患者的 ICD-9 评估记录充分，98 名患者的图表信息足以进行回顾性审查。各组的总体并发症发生率相似（主要并发症：ICD-9 17.4%，回顾性 19.4%，前瞻性 22.4%；小并发症：ICD-9 43.8%，回顾性 31.6%，前瞻性 42.9%）。然而，基于 ICD-9 的评估包括许多审核员认为不是并发症的小医疗事件。在 ICD-9 和回顾性评估中，特定并发症的发生率都被一致低估。ICD-9 评估低估了感染、需要再次手术、深部伤口感染、深静脉血栓形成和新的神经功能缺损的发生率（p = 0.003、p < 0.0001、p < 0.0001、p = 0.0025 和 p = 0.04，分别）。回顾性审查低估了感染、需要修订和深部伤口感染的发生率（p < 0.0001）。只有在新的心脏事件的捕获中，基于 ICD-9 的报告比前瞻性数据累积更准确（p = 0.04）。对并发症发生的最敏感评估是前瞻性审查，其次是基于 ICD-9 的评估（p = 0.05）。
在接受脊柱手术的患者队列中，基于 ICD-9 的围手术期不良事件和主要并发症编码显示出与前瞻性执行的测量结果相似的总体并发症发生率。相比之下，回顾性审查低估了并发症的发生率。基于 ICD-9 的审查捕获了许多临床意义有限的医疗事件，从而增加了这种方法显示的不良事件的总体发生率。在多个主要的、有临床意义的围手术期并发症类别中，基于 ICD-9 的和回顾性评估严重低估了并发症的发生率。这些发现表明，基于人群的 ICD-9 和回顾性并发症记录的使用存在重大潜在弱点和不准确来源。
