Division of Maternal-Fetal Fetal Medicine, Department of Obstetrics and Gynecology, College of Physicians and Surgeons, Columbia University Irving Medical Center, New York, NY, USA.
New York Presbyterian, Value Institute, New York, NY, USA.
J Matern Fetal Neonatal Med. 2022 Jun;35(12):2234-2240. doi: 10.1080/14767058.2020.1783229. Epub 2020 Jun 29.
Measurement of obstetric hemorrhage-related morbidity is important for quality assurance purposes but presents logistical challenges in large populations. Billing codes are typically used to track severe maternal morbidity but may be of suboptimal validity. The objective of this study was to evaluate the validity of billing code diagnoses for hemorrhage-related morbidity compared to data obtained from the electronic medical record.
Deliveries occurring between July 2014 and July 2017 from three hospitals within a single system were analyzed. Three outcomes related to obstetric hemorrhage that are part of the Centers for Disease Control and Prevention definition of severe maternal morbidity (SMM) were evaluated: (i) transfusion, (ii) disseminated intravascular coagulation (DIC), and (iii) acute renal failure (ARF). ICD-9-CM and ICD-10-CM for these conditions were ascertained and compared to blood bank records and laboratory values. Sensitivity, specificity, positive (PPV) and negative predictive values (NPV) with 95% confidence intervals (CI) were calculated. Ancillary analyses were performed comparing codes and outcomes between hospitals and comparing ICD-9-CM to ICD-10-CM codes. Comparisons of categorical variables were performed with the chi-squared test. T-tests were used to compare continuous outcomes.
35,518 deliveries were analyzed. 786 women underwent transfusion, 168 had serum creatinine ≥1.2 mg/dL, and 99, 40, and 16 had fibrinogen ≤200, ≤150, and ≤100 mg/dL, respectively. Transfusion codes were 65% sensitive (95% CI 62-69%) with a 91% PPV (89-94%) for blood bank records of transfusion. DIC codes were 22% sensitive (95% CI 15-32%) for a fibrinogen cutoff of ≤200 mg/dL with 15% PPV (95% CI 10-22%). Sensitivity for ARF was 33% (95% CI 26-41%) for a creatinine of 1.2 mg/dL with a PPV of 63% (95% CI 52-73%). Sensitivity of ICD-9-CM for transfusion was significantly higher than ICD-10-CM (81%, 95% CI 76-86% versus 56%, 95% CI 51-60%, < .01). Evaluating sensitivity of codes by individual hospitals, sensitivity of diagnosis codes for transfusion varied significantly (Hospital A 47%, 95% CI 36-58% versus Hospital B 63%, 95% CI 58-67% versus Hospital C 80%, 95% CI 74-86%, < .01).
Use of administrative billing codes for postpartum hemorrhage complications may be appropriate for measuring trends related to disease burden and resource utilization, particularly in the case of transfusion, but may be suboptimal for measuring clinical outcomes within and between hospitals.
衡量产科出血相关发病率对于质量保证至关重要，但在大人群中存在后勤方面的挑战。计费代码通常用于跟踪严重产妇发病率，但可能存在不太理想的有效性。本研究的目的是评估计费代码诊断与出血相关发病率之间的有效性，与从电子病历中获得的数据进行比较。
分析了 2014 年 7 月至 2017 年 7 月期间在一个系统内的三家医院的分娩情况。评估了与产科出血相关的三种符合疾病预防控制中心定义的严重产妇发病率（SMM）的结果：（i）输血，（ii）弥散性血管内凝血（DIC）和（iii）急性肾功能衰竭（ARF）。确定了这些病症的 ICD-9-CM 和 ICD-10-CM，并与血库记录和实验室值进行了比较。计算了敏感性、特异性、阳性预测值（PPV）和阴性预测值（NPV），置信区间为 95%。进行了医院间代码和结果的辅助分析比较，以及 ICD-9-CM 与 ICD-10-CM 代码的比较。比较了分类变量的卡方检验。使用 t 检验比较连续结果。
分析了 35518 次分娩。786 名妇女接受了输血，168 名妇女血清肌酐≥1.2mg/dL，99、40 和 16 名妇女的纤维蛋白原分别为≤200、≤150 和≤100mg/dL。输血代码的敏感性为 65%（95%CI 62-69%），与输血的血库记录相比，PPV 为 91%（89-94%）。DIC 代码对纤维蛋白原≤200mg/dL 的灵敏度为 22%（95%CI 15-32%），PPV 为 15%（95%CI 10-22%）。ARF 的灵敏度为 33%（95%CI 26-41%），肌酐为 1.2mg/dL，PPV 为 63%（95%CI 52-73%）。ICD-9-CM 对输血的敏感性明显高于 ICD-10-CM（81%，95%CI 76-86%比 56%，95%CI 51-60%， < .01）。按单个医院评估代码的敏感性，输血诊断代码的敏感性差异显著（医院 A 为 47%，95%CI 36-58%，医院 B 为 63%，95%CI 58-67%，医院 C 为 80%，95%CI 74-86%， < .01）。
使用行政计费代码来衡量产后出血并发症可能适合衡量与疾病负担和资源利用相关的趋势，特别是在输血的情况下，但在衡量医院内和医院间的临床结果时可能不太理想。
