Accurate Identification of Patients with Cirrhosis and Its Complications in the Electronic Health Record

Khalifa, Ali; Obeid, Jihad S.; Gregoski, Mathew J.

doi:10.1007/s10620-023-07876-7

Cited by 3 publications

(10 citation statements)

References 19 publications

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“…The identification of patients with cirrhosis on electronic medical records also often represents a challenge given the variable accuracy of ICD codes. 31 , 32 To increase the accuracy of cirrhosis diagnosis, we employed a natural language process model for the detection of imaging features of cirrhosis and portal hypertension. This approach may have led to the selection of patients with more advanced stages of cirrhosis.…”

Section: Discussionmentioning

confidence: 99%

Serum lactate and mean arterial pressure thresholds in patients with cirrhosis and septic shock

Smith,

Choi,

Rattan

et al. 2024

Hepatology Communications

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Background: The Sepsis-3 guidelines have incorporated serum lactate levels of >2 mmol/L in septic shock definition to account for higher observed mortality. Further evidence is needed to support this threshold in cirrhosis, as well as target mean arterial pressure (MAP) during resuscitation. Methods: This observational cohort study investigated the association between initial serum lactate and resuscitation MAP levels on in-hospital mortality in patients with and without cirrhosis. Patients admitted to the intensive care unit for the treatment of septic shock between 2006 and 2021 in a quaternary academic center were included. Patients with cirrhosis documented on imaging and International Classification of Disease codes (n=595) were compared to patients without cirrhosis (n=575). The association of intensive care unit admission lactate levels and median 2-hour MAP with in-hospital mortality and the need for continuous renal replacement therapy was assessed. The association between median 24-hour MAP and in-hospital mortality was analyzed post hoc. Results: Within the cirrhosis group, admission lactate levels of 2–4 and >4 mmol/L were associated with increased in-hospital mortality compared to lactate <2 mmol/L [adjusted odds ratio (aOR): 1.69, CI: 1.03–2.81, aOR: 4.02, CI: 2.53–6.52]. Median 24-hour MAP 60–65 and <60 mm Hg were also associated with increased in-hospital mortality compared with MAP >65 mm Hg (aOR: 2.84, CI: 1.64–4.92 and aOR: 7.34, CI: 3.17–18.76). In the noncirrhosis group, associations with in-hospital mortality were weaker for lactate 2–4 and >4 mmol/L (aOR: 1.32, CI: 0.77–2.27 and aOR: 2.25, CI: 1.40–3.67) and median 24-hour MAP 60–65 and <60 mm Hg (aOR: 1.70, CI: 0.65–4.14 and aOR: 4.41, CI: 0.79–29.38). Conclusions: These findings support utilizing lactate >2 mmol/L in the definition of septic shock, as well as a target MAP of >65 mm Hg during resuscitation in patients with cirrhosis.

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Section: Discussionmentioning

confidence: 99%

Serum lactate and mean arterial pressure thresholds in patients with cirrhosis and septic shock

Smith,

Choi,

Rattan

et al. 2024

Hepatology Communications

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“… 23 In addition, the PPV of our NAC algorithms may be lower in our study, compared to previous validation studies examining these NAC codes, since the prevalence of NAC was lower in our cohort (29% vs. 42%–76%). 11 , 14 , 21 Population-level studies that require a higher PPV for NAC case identification could use NAC algorithm #2 (NAC ICD-10 codes in any position, excluding AUD codes; PPV 84.1%, CI: 76.7–89.9); however, this algorithm is limited by low sensitivity and has a statistically lower AUROC compared to NAC algorithm #9.1. Including codes for ascites, unspecified encephalopathy, secondary esophageal varices, gastric varices, esophageal varices without/with bleeding in diseases classified elsewhere, unspecified peritonitis, and acute hepatic failure either did not alter or decreased NAC identification accuracy in our cohort.…”

Section: Discussionmentioning

confidence: 99%

“…Previous validation studies have used these codes to enhance cirrhosis identification, a finding that contrasts with our observations. 9 , 11 , 14 However, these previous studies assessed algorithms using cohorts with known pre-existing cirrhosis or from tertiary hepatology care centers, which could impact liver disease code accuracy.…”

Section: Discussionmentioning

confidence: 99%

“…A) NAC codes alone: We identified 4 cirrhosis ICD-10 codes that have previously been used for both NAC and cirrhosis case identification (Supplemental Table S1, http://links.lww.com/HC9/A929 and S2, http://links.lww.com/HC9/A929 ). These ICD-10 codes include K74.6 (other and unspecified cirrhosis of liver; PPV 89%–96%), 11 – 14 , 21 , 36 K74.4 (secondary biliary cirrhosis; PPV 100%), 11 K74.5 (biliary cirrhosis unspecified; PPV 67%), 11 and K71.7 (toxic liver disease with cirrhosis; PPV 100%). 13 We examined NAC case identification accuracy using the NAC codes in any diagnostic position (NAC algorithm #1), the primary diagnostic position (NAC algorithm #1.1), and the secondary diagnostic position (NAC algorithm #1.2).…”

Section: Methodsmentioning

confidence: 99%

“…To date, methods that have been used to identify AC-specific hospitalizations had low positive predictive value (PPV) and sensitivity or have not been thoroughly validated in a general patient sample. [9,[11][12][13][14][15][16][17][18][19][20][21][22] Two commonly employed AC identification methods use either the primary AC ICD-10 code alone (PPV; 66%-100%; sensitivity 7%-52%), [9,[11][12][13][14][15] or alcohol use disorder (AUD) ICD-10 codes together with cirrhosis codes (PPV 40%-82%; sensitivity 80%-90%) [22] (Supplemental Table S1, http://links.lww.com/HC9/A929). Both of these methods rely on AC admissions having a cirrhosis diagnostic code, but not all AC admissions are accurately coded with a cirrhosis code.…”

Section: Introductionmentioning

confidence: 99%

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Validating new coding algorithms to improve identification of alcohol-associated and nonalcohol-associated cirrhosis hospitalizations in administrative databases

Swain,

Godley,

Brahmania

et al. 2024

Hepatology Communications

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Background: Alcohol (AC) and nonalcohol-associated cirrhosis (NAC) epidemiology studies are limited by available case definitions. We compared the diagnostic accuracy of previous and newly developed case definitions to identify AC and NAC hospitalizations. Methods: We randomly selected 700 hospitalizations from the 2008 to 2022 Canadian Discharge Abstract Database with alcohol-associated and cirrhosis-related International Classification of Diseases 10th revision codes. We compared standard approaches for AC (ie, AC code alone and alcohol use disorder and nonspecific cirrhosis codes together) and NAC (ie, NAC codes alone) case identification to newly developed approaches that combine standard approaches with new code combinations. Using electronic medical record review as the reference standard, we calculated case definition positive and negative predictive values, sensitivity, specificity, and AUROC. Results: Electronic medical records were available for 671 admissions; 252 had confirmed AC and 195 NAC. Compared to previous AC definitions, the newly developed algorithm selecting for the AC code, alcohol-associated hepatic failure code, or alcohol use disorder code with a decompensated cirrhosis-related condition or NAC code provided the best overall positive predictive value (91%, 95% CI: 87–95), negative predictive value (89%, CI: 86–92), sensitivity (81%, CI: 76–86), specificity (96%, CI: 93–97), and AUROC (0.88, CI: 0.85–0.91). Comparing all evaluated NAC definitions, high sensitivity (92%, CI: 87–95), specificity (82%, CI: 79–86), negative predictive value (96%, CI: 94–98), AUROC (0.87, CI: 0.84–0.90), but relatively low positive predictive value (68%, CI: 62–74) were obtained by excluding alcohol use disorder codes and using either a NAC code in any diagnostic position or a primary diagnostic code for HCC, unspecified/chronic hepatic failure, esophageal varices without bleeding, or hepatorenal syndrome. Conclusions: New case definitions show enhanced accuracy for identifying hospitalizations for AC and NAC compared to previously used approaches.

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The primary cause of markedly elevated aminotransferases in hospitalized patients with cirrhosis in ischemic hepatitis

Allam,

Ibrahim,

Rockey

2024

European Journal of Gastroenterology &Amp; Hepatology

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Background Marked elevation in aminotransferases (≥1000 IU/l) is typically associated with acute liver injury. Here, we hypothesized that the cause of elevation in aminotransferases ≥1000 in patients with cirrhosis is likely due to a limited number of disorders and may be associated with poor outcomes. Aim We aimed to investigate the most common etiologies of acute elevations in aminotransferases in patients with cirrhosis, and to examine their associated outcomes. Methods From May 2012 to December 2022, all hospitalized patients with cirrhosis and an aspartate aminotransferase or alanine aminotransferase ≥ 1000 IU/l were identified through Medical University of South Carolina’s Clinical Data Warehouse. Complete clinical data were abstracted for each patient, and in-hospital mortality was examined. Results The cohort was made up of 152 patients, who were 57 ± 12 years old, with 51 (34%) women. Underlying liver disease included mainly hepatitis C cirrhosis, alcohol-related cirrhosis, metabolic dysfunction-associated steatohepatitis cirrhosis, autoimmune cirrhosis, primary sclerosing cholangitis cirrhosis, and cryptogenic cirrhosis. The most common cause of marked elevation in aminotransferases in cirrhotic patients was ischemic hepatitis (71%), followed by chemoembolization (7%), autoimmune hepatitis (6%), drug-induced liver injury (3%), post-transjugular intrahepatic portosystemic shunt placement (3%), rhabdomyolysis (3%), and hepatitis C (2%). During hospitalization and over a 1-month follow-up period, the mortality rate in patients with ischemic hepatitis was 73% (79/108), while that for other causes of liver injury was 20% (9/44). Conclusion Ischemic hepatitis is the leading cause of marked elevation of aminotransferases in patients with cirrhosis, with distinctive clinical characteristics than other etiologies, and significantly poorer outcomes.

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Accurate Identification of Patients with Cirrhosis and Its Complications in the Electronic Health Record

Cited by 3 publications

References 19 publications

Serum lactate and mean arterial pressure thresholds in patients with cirrhosis and septic shock

Serum lactate and mean arterial pressure thresholds in patients with cirrhosis and septic shock

Validating new coding algorithms to improve identification of alcohol-associated and nonalcohol-associated cirrhosis hospitalizations in administrative databases

The primary cause of markedly elevated aminotransferases in hospitalized patients with cirrhosis in ischemic hepatitis

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