Foster Nichola, Raby Edward, Wood Fiona M, Fear Mark, Pavlos Nathan, Edgar Dale W
Burn Injury Research Node, Institute for Health Research / School of Physiotherapy, The University of Notre Dame Australia, Fremantle, Western Australia, 6160, Australia; Burn Injury Research Unit and Fiona Wood Foundation, University of Western Australia, Nedlands, Western Australia, 6009, Australia; Physiotherapy Department, Sir Charles Gairdner Osborne Park Health Care Group, North Metropolitan Health Service, Nedlands, Western Australia, 6009, Australia.
Burn Injury Research Unit and Fiona Wood Foundation, University of Western Australia, Nedlands, Western Australia, 6009, Australia; State Adult Burn Unit, Fiona Stanley Hospital, Murdoch, Western Australia, 6150, Australia.
Injury. 2024 Mar;55(3):111329. doi: 10.1016/j.injury.2024.111329. Epub 2024 Jan 17.
Traumatic heterotopic ossification (tHO) refers to the pathological formation of ectopic bone in soft tissues that can occur following burn, neurological ororthopaedic trauma. As completeness and accuracy of medical diagnostic coding can vary based on coding practices and depend on the institutional culture of clinical documentation, it is important to assess diagnostic coding in that local context. To the authors' knowledge, there is no prior study evaluating the accuracy of medical diagnostic coding or specificity of clinical documentation for tHO diagnoses across Western Australia (WA) trauma centres or across the full range of inciting injury and surgical events.
To evaluate and compare the clinical documentation and the diagnostic accuracy of ICD-10-AM coding for tHO in trauma populations across 4 WA hospitals.
A retrospective data search of the WA trauma database was conducted to identify patients with tHO admitted to WA hospitals following burn, neurological or orthopaedic trauma. Patient demographic and tHO diagnostic characteristics were assessed for all inpatient and outpatient tHO diagnoses. The frequency and distribution of M61 (HO-specific) and broader, musculoskeletal (non-specific) ICD-10-AM codes were evaluated for tHO cases in each trauma population.
HO-specific M61 ICD-10-AM codes failed to identify more than a third of true tHO cases, with a high prevalence of non-specific HO codes (19.4 %) and cases identified via manual chart review (25.4 %). The sensitivity of M61 codes for correctly diagnosing tHO after burn injury was 50 %. ROC analysis showed that M61 ICD-10-AM codes as a predictor of a true positive tHO diagnosis were a less than favourable method (AUC=0.731, 95 % CI=0.561-0.902, p = 0.012). Marked variability in clinical documentation for tHO was identified across the hospital network.
Coding inaccuracies may, in part, be influenced by insufficiencies in clinical documentation for tHO diagnoses, which may have implications for future research and patient care. Clinicians should consistently employ standardised clinical terminology from the point of care to increase the likelihood of accurate medical diagnostic coding for tHO diagnoses.
创伤性异位骨化（tHO）是指在烧伤、神经或骨科创伤后，软组织中异位骨的病理性形成。由于医学诊断编码的完整性和准确性可能因编码实践而异，并取决于临床文档的机构文化，因此在当地背景下评估诊断编码很重要。据作者所知，此前尚无研究评估西澳大利亚州（WA）创伤中心或所有引发损伤和手术事件的医疗诊断编码准确性或tHO诊断临床文档的特异性。
评估并比较西澳大利亚州4家医院创伤人群中tHO的临床文档及ICD-10-AM编码的诊断准确性。
对WA创伤数据库进行回顾性数据检索，以识别因烧伤、神经或骨科创伤后入住WA医院的tHO患者。对所有住院和门诊tHO诊断的患者人口统计学和tHO诊断特征进行评估。评估了每个创伤人群中tHO病例的M61（特定于HO）和更广泛的肌肉骨骼（非特定）ICD-10-AM编码的频率和分布。
特定于HO的M61 ICD-10-AM编码未能识别超过三分之一的真正tHO病例，非特定HO编码的患病率很高（19.4%），通过人工病历审查识别的病例（25.4%）也是如此。烧伤后M61编码正确诊断tHO的敏感性为５０％。ROC分析表明，M61 ICD-10-AM编码作为真正阳性tHO诊断的预测指标并非理想方法（AUC=0.731，95%CI=0.561-0.902，p=0.012）。在整个医院网络中，tHO的临床文档存在明显差异。
编码不准确可能部分受到tHO诊断临床文档不足的影响，这可能对未来的研究和患者护理产生影响。临床医生应在医疗护理过程中始终使用标准化的临床术语，以提高tHO诊断的准确医疗诊断编码的可能性。
