Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Mass.
Department of Surgery, Division of Vascular Surgery, University Medical Center, Utrecht, The Netherlands.
J Vasc Surg. 2014 Jan;59(1):32-8.e1. doi: 10.1016/j.jvs.2013.07.006. Epub 2013 Aug 28.
Administrative data are often hampered by coding errors, absent data, and the difficulty of distinguishing pre-existing conditions from perioperative complications. We evaluated whether the introduction of the present on admission (POA) indicator improved outcome analysis of carotid endarterectomy (CEA) and carotid angioplasty and stenting (CAS) using administrative data.
State inpatient databases from California (2005-2008), New York (2008), and New Jersey (2008) were used to identify patients undergoing CAS and CEA. We first analyzed morbidity data without the POA indicator, using International Classification of Diseases, Ninth Revision complication codes (eg, 997.02, iatrogenic cerebrovascular infarction or hemorrhage, postoperative stroke) and diagnosis codes (eg, 433.11, occlusion and stenosis of the carotid artery with cerebral infarction). Then, we applied the POA indicator to both diagnosis and complication codes and calculated the proportion of events that were labeled POA. Symptom status and perioperative stroke rate were compared using these coding approaches.
We identified 21,639 patients who underwent CEA and 3688 patients who underwent CAS. Without the POA indicator, the complication code for stroke indicated a postoperative stroke rate of 1.4% for CEA and 2.4% for CAS. After applying the POA indicator, 54% (CEA) and 62% (CAS) of these strokes were labeled POA. These POA strokes were either preoperative or intraoperative events. Proportion of symptomatic patients ranged from 7% to 16% for CEA and from 5% to 22% for CAS. Perioperative stroke rate was the lowest in the POA method (1.1% CEA, 1.8% CAS) compared with two other methods without POA information (1.4% and 9.5% CEA and 2.4% and 16.4% CAS). Kappa indicated a poor (0.2) to fair (0.7) agreement between these approaches.
Administrative data has known limitations for assignment of symptom status and nonfatal perioperative outcomes. Given the uncertain timing of POA events as preoperative vs intraoperative and its apparent underestimation of the perioperative stroke rate, the use of administrative data even with the POA indicator for symptom status and non-fatal outcomes after CEA and CAS is hazardous.
行政数据常常受到编码错误、数据缺失以及难以区分术前疾病与围手术期并发症的影响。我们评估了入院时现患情况（POA）指标的引入是否改善了使用行政数据进行颈动脉内膜切除术（CEA）和颈动脉血管成形术及支架置入术（CAS）的结果分析。
使用加利福尼亚州（2005-2008 年）、纽约州（2008 年）和新泽西州（2008 年）的州住院患者数据库，确定接受 CAS 和 CEA 的患者。我们首先使用国际疾病分类，第九版并发症代码（例如，997.02，医源性脑血管梗死或出血，术后中风）和诊断代码（例如，433.11，颈动脉闭塞和狭窄伴脑梗死）分析无 POA 指标的发病率数据。然后，我们将 POA 指标应用于诊断和并发症代码，并计算标记为 POA 的事件比例。使用这些编码方法比较症状状态和围手术期中风发生率。
我们确定了 21639 例 CEA 患者和 3688 例 CAS 患者。没有 POA 指标时，中风的并发症代码显示 CEA 的术后中风发生率为 1.4%，CAS 为 2.4%。应用 POA 指标后，这些中风的 54%（CEA）和 62%（CAS）被标记为 POA。这些 POA 中风为术前或术中事件。CEA 的有症状患者比例为 7%至 16%，CAS 为 5%至 22%。与没有 POA 信息的两种其他方法（CEA 为 1.4%和 9.5%，CAS 为 2.4%和 16.4%）相比，POA 方法的围手术期中风发生率最低（CEA 为 1.1%，CAS 为 1.8%）。Kappa 表示这些方法之间的一致性较差（0.2）至中等（0.7）。
行政数据在确定症状状态和非致命围手术期结果方面存在已知的局限性。鉴于 POA 事件的时间不确定，为术前或术中事件，并且明显低估了围手术期中风的发生率，因此即使使用行政数据和 POA 指标，CEA 和 CAS 后的症状状态和非致命结果也存在风险。
