A Study of Clinical Coding Accuracy in Surgery

Background: A recent study estimated that more than 1.5 million Americans have an indeterminate pulmonary nodule (IPN) identified on a chest computed tomography (CT) scan each year outside of lung cancer screening programs. However, the cost and pattern of subsequent IPN workup have not been described for real-world settings.</p> Objectives: To examine the pattern and cost of IPN workup in real-world practice using insurer administrative claims data for commercially-insured individuals. Methods: The primary source for this retrospective observational study was the MarketScan® 2013-2016 databases, which include information on 28 to 47 million insured lives. The newly diagnosed IPN study population consisted of members with an IPN diagnosis code on a claim in 2014 who did not have prior diagnosis of an IPN or lung cancer in 2013 and who had coverage from 2014 to 2016. Subsequent claims were examined for workups included in the American College of Chest Physicians (ACCP) guideline recommendations and the costs of workup were tabulated. Results: Of the 15 064 patients in the study population, only 5471 (36%) received any subsequent workup. The average and median costs of workup for these patients were $3270 and $2068, respectively. Spread across the commercially-insured population, the workup is estimated to cost between $1 and $2 per member per year. Conclusions: The majority of commercially-insured members with newly identified IPNs do not appear to have any guideline-recommended workup, despite a low incremental cost of such workup services on a population basis.

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“…Furthermore, the diagnoses and procedures that appear in administrative data may be incomplete and may include errors. 17 , 18 …”

Section: Limitationsmentioning

confidence: 99%

No Apparent Workup for most new Indeterminate Pulmonary Nodules in US Commercially-Insured Patients

Pyenson

Bazell

Bellanich

et al. 2019

JHEOR

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“…Such data might be more satisfactory in identifying surgical procedures, cancer, or rare diseases, but in conditions for which patients are most likely to be admitted to hospital acutely, coding accuracy is known to be poor. 11 14 31 Fourthly, as coding accuracy might differ between countries and healthcare systems, the coding related biases we reported using UK data might not be generalisable to other countries. Recent data from countries using different coding practices to the UK, however, also reported low sensitivity and positive predictive value with administrative data alone in identifying acute stroke.…”

Section: Discussionmentioning

confidence: 95%

Biases in detection of apparent “weekend effect” on outcome with administrative coding data: population based study of stroke

Rothwell

2016

BMJ

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Objectives To determine the accuracy of coding of admissions for stroke on weekdays versus weekends and any impact on apparent outcome.Design Prospective population based stroke incidence study and a scoping review of previous studies of weekend effects in stroke.Setting Primary and secondary care of all individuals registered with nine general practices in Oxfordshire, United Kingdom (OXVASC, the Oxford Vascular Study).Participants All patients with clinically confirmed acute stroke in OXVASC identified with multiple overlapping methods of ascertainment in 2002-14 versus all acute stroke admissions identified by hospital diagnostic and mortality coding alone during the same period.Main outcomes measures Accuracy of administrative coding data for all patients with confirmed stroke admitted to hospital in OXVASC. Difference between rates of “false positive” or “false negative” coding for weekday and weekend admissions. Impact of inaccurate coding on apparent case fatality at 30 days in weekday versus weekend admissions. Weekend effects on outcomes in patients with confirmed stroke admitted to hospital in OXVASC and impacts of other potential biases compared with those in the scoping review.Results Among 92 728 study population, 2373 episodes of acute stroke were ascertained in OXVASC, of which 826 (34.8%) mainly minor events were managed without hospital admission, 60 (2.5%) occurred out of the area or abroad, and 195 (8.2%) occurred in hospital during an admission for a different reason. Of 1292 local hospital admissions for acute stroke, 973 (75.3%) were correctly identified by administrative coding. There was no bias in distribution of weekend versus weekday admission of the 319 strokes missed by coding. Of 1693 admissions for stroke identified by coding, 1055 (62.3%) were confirmed to be acute strokes after case adjudication. Among the 638 false positive coded cases, patients were more likely to be admitted on weekdays than at weekends (536 (41.0%) v 102 (26.5%); P<0.001), partly because of weekday elective admissions after previous stroke being miscoded as new stroke episodes (267 (49.8%) v 26 (25.5%); P<0.001). The 30 day case fatality after these elective admissions was lower than after confirmed acute stroke admissions (11 (3.8%) v 233 (22.1%); P<0.001). Consequently, relative 30 day case fatality for weekend versus weekday admissions differed (P<0.001) between correctly coded acute stroke admissions and false positive coding cases. Results were consistent when only the 1327 emergency cases identified by “admission method” from coding were included, with more false positive cases with low case fatality (35 (14.7%)) being included for weekday versus weekend admissions (190 (19.5%) v 48 (13.7%), P<0.02). Among all acute stroke admissions in OXVASC, there was no imbalance in baseline stroke severity for weekends versus weekdays and no difference in case fatality at 30 days (adjusted odds ratio 0.85, 95% confidence interval 0.63 to 1.15; P=0.30) or any adverse “weekend effect” on modified Rankin score at 30 da...

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“…Hospital reimbursement is based on the diagnosis and procedure codes recorded in HES, therefore there are incentives for these data to be comprehensively recorded. However, this is routine data so will inevitably contain data entry errors; for example, an audit between 2010 and 2013 found that 13% of primary diagnoses and 12% of primary procedures were coded incorrectly [ 22 ]. Our analysis only includes patients admitted to hospital so we cannot determine the incidence of ankle fractures managed non-surgically in the emergency department or in outpatient appointments.…”

Section: Discussionmentioning

confidence: 99%

Exploring trends in admissions and treatment for ankle fractures: a longitudinal cohort study of routinely collected hospital data in England

Scott

Jones

Whitehouse

et al. 2020

BMC Health Serv Res

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Background: Evidence on the most effective and cost-effective management of ankle fractures is sparse but evolving. A recent large RCT in older patients with unstable fractures found that management with close-contactcasting was functionally equivalent and more cost-effective than internal fixation. We describe temporal and geographic variation in ankle fracture management and estimate the potential savings if close-contact-casting was used more often in older patients. Methods: Patients admitted to hospital in England between 2007/08 and 2016/17 with an ankle fracture were identified using routine hospital episode statistics. We tested whether the use of internal fixation, and the proportion of internal fixations using intramedullary implants, changed over time. We estimated the potential annual cost savings if patients aged 60+ years were treated with close-contact-casting rather than internal fixation, in line with emerging evidence. Results: Over the 10-year period, there were 223,465 hospital admissions with a primary ankle fracture diagnosis. The incidence (per 100,000) of internal fixation was fairly consistent over time in younger (33.2 in 2007/08, 30.9 in 2016/17) and older (36.5 in 2007/08, 37.4 in 2016/17) patients. The proportion of internal fixations which used intramedullary implants increased in both age groups (17.0-19.5% < 60 years; 15.2-17.4% 60+ years). In 2016/17, the cost of inpatient hospital care for ankle fractures in England was over £63.1million. If 50% of older patients who had an internal fixation instead had close-contact-casting, we estimate that approximately £1.56million could have been saved. Conclusions: Despite emerging evidence that non-surgical and surgical management achieve equivalent functional outcomes in older patients, the rate of surgical fixation has remained relatively stable over the decade. The health service could achieve substantial savings if a higher proportion of older patients were treated with close-contactcasting, in line with recent evidence.

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A Study of Clinical Coding Accuracy in Surgery

Cited by 61 publications

References 13 publications

No Apparent Workup for most new Indeterminate Pulmonary Nodules in US Commercially-Insured Patients

No Apparent Workup for most new Indeterminate Pulmonary Nodules in US Commercially-Insured Patients

Biases in detection of apparent “weekend effect” on outcome with administrative coding data: population based study of stroke

Exploring trends in admissions and treatment for ankle fractures: a longitudinal cohort study of routinely collected hospital data in England

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