DeGroot David W, Mok Gordon, Hathaway Nathanael E
Tripler Army Medical Center, 1 Jarrett White Road, Honolulu, HI 96859.
U.S. Army Health Clinic Hohenfels, Hohenfels, Bavaria, CMR 414 Box 768, APO, AE 09173.
Mil Med. 2017 Sep;182(9):e1946-e1950. doi: 10.7205/MILMED-D-16-00429.
The severity of exertional heat illnesses (EHI) ranges from relatively minor heat exhaustion to potentially life-threatening heat stroke. Epidemiological surveillance of the types of and trends in EHI incidence depends on application of the appropriate International Classification of Disease, 9th Revision (ICD-9) diagnostic code. However, data examining whether the appropriate EHI ICD-9 code is selected are lacking. The purpose of this study was to determine whether the appropriate ICD-9 code is selected in a cohort of EHI casualties.
Chart reviews of 290 EHI casualties that occurred in U.S. Army soldiers from 2009 to 2012 were conducted. The ICD-9 diagnostic code was extracted, as were the initial and peak values for aspartate transaminase, alanine transaminase, creatine kinase, and creatinine. Diagnostic criteria for heat injury and heat stroke include evidence of organ and/or tissue damage; 2 out of 3 of the following must have been met to be considered heat injury (ICD-9 code 992.8) or heat stroke (ICD-9 code 992.0): aspartate transaminase/ alanine transaminase fold increase >3, creatine kinase fold increase >5, and/or creatinine ≥1.5mg/dL. Contingency tables were constructed from which sensitivity, specificity, and positive and negative predictive value were calculated.
The 290 cases in this cohort represent ∼29% of all EHI at Fort Benning and ∼6% of all EHI Army-wide during the study period. There were 80 cases that met the laboratory diagnostic criteria for heat injury/stroke, however of those, 28 cases were diagnosed as an EHI other than heat injury/stroke (sensitivity = 0.65). 210 cases did not meet the laboratory diagnostic criteria, but 66 of those were incorrectly diagnosed as heat injury or heat stroke (specificity = 0.69). Positive and negative predictive values were 0.44 and 0.84, respectively. In total, the incorrect ICD-9 code was applied to 94 of 290 total cases.
Our data suggest that caution is warranted when examining epidemiological surveillance data on EHI severity, as there was disagreement between the laboratory data and the selected ICD-9 code in ∼1/3 of all cases in this cohort. Of note is the lack of an ICD-9 or -10 code for heat injury; we recommend coding for heat exhaustion as the primary diagnosis and additional codes to capture the accompanying muscle, tissue, and/or organ damage.
劳力性热疾病（EHI）的严重程度从相对轻微的热衰竭到可能危及生命的中暑不等。对EHI发病率的类型和趋势进行流行病学监测取决于应用适当的《国际疾病分类》第九版（ICD - 9）诊断代码。然而，缺乏关于是否选择了适当的EHI ICD - 9代码的数据。本研究的目的是确定在一组EHI伤亡人员中是否选择了适当的ICD - 9代码。
对2009年至2012年在美国陆军士兵中发生的290例EHI伤亡人员的病历进行了回顾。提取了ICD - 9诊断代码，以及天冬氨酸转氨酶、丙氨酸转氨酶、肌酸激酶和肌酐的初始值和峰值。热损伤和中暑的诊断标准包括器官和/或组织损伤的证据；要被视为热损伤（ICD - 9代码992.8）或中暑（ICD - 9代码992.0），必须满足以下三项中的两项：天冬氨酸转氨酶/丙氨酸转氨酶升高倍数>3、肌酸激酶升高倍数>5和/或肌酐≥1.5mg/dL。构建了列联表，并计算了敏感性、特异性以及阳性和阴性预测值。
该队列中的290例病例约占本宁堡所有EHI病例的29%，约占研究期间全军所有EHI病例的6%。有80例病例符合热损伤/中暑的实验室诊断标准，然而其中28例被诊断为除热损伤/中暑之外的EHI（敏感性 = 0.65）。210例病例不符合实验室诊断标准，但其中66例被错误诊断为热损伤或中暑（特异性 = 0.69）。阳性和阴性预测值分别为0.44和0.84。在总共290例病例中，有94例应用了错误的ICD - 9代码。
我们的数据表明，在检查关于EHI严重程度的流行病学监测数据时应谨慎，因为在该队列中约三分之一的病例中，实验室数据与所选的ICD - 9代码存在分歧。值得注意的是，热损伤没有ICD - 9或 - 10代码；我们建议将热衰竭编码为主要诊断，并使用附加代码来记录伴随的肌肉、组织和/或器官损伤。
