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Case Ascertainment in Pediatric Heart Failure Using International Classification of Disease Clinical Modification
Lindsay J May1, Josef Stehlik2, Jacob Wilkes3
1University of Utah.
Insights
Identifying pediatric heart failure (HF) using ICD codes is challenging. Combining HF ICD codes with medication data improves accuracy in electronic health records, but further refinement is needed for large datasets.
Area of Science:
- Pediatric Cardiology
- Health Informatics
- Epidemiology
Background:
- Epidemiological studies of pediatric heart failure (HF) often rely on administrative databases and International Classification of Diseases (ICD) codes.
- The accuracy of using single HF ICD codes to identify pediatric HF patients in electronic data is not well-established.
Purpose of the Study:
- To evaluate the accuracy of HF ICD-10-CM code search algorithms in identifying pediatric patients with heart failure from electronic data sources.
- To compare the performance of algorithms incorporating ICD codes alone versus those combining ICD codes with medication data.
Main Methods:
- Developed and tested HF search algorithms based on adult HF literature, incorporating HF ICD codes, imaging, and medications.
- Validated algorithms in an advanced HF clinic cohort and subsequently in a large regional electronic data warehouse (EDW) from 01/2017 to 01/2020.
- Conducted chart review to identify and characterize false positive cases.
Main Results:
- In the clinic cohort, algorithms combining one HF ICD code with HF medication demonstrated the highest accuracy (93%).
- In the EDW cohort, algorithms using >1 HF ICD code or one HF ICD code with medication were tested.
- A significant proportion of false positives in the EDW cohort (46.3%) were due to pulmonary overcirculation from congenital heart disease; this proportion decreased to 20% after excluding specific patient groups.
Conclusions:
- A single HF ICD code search algorithm can achieve acceptable accuracy for identifying pediatric HF in electronic medical records.
- Incorporating HF medication data enhances algorithm specificity, similar to findings in adult HF research.
- Large-scale application of these algorithms necessitates careful consideration of false positives, particularly those related to congenital heart disease, suggesting a need for integrated data sources (administrative, surgical, imaging) for precise case identification.
Background:
Most epidemiological studies in pediatric heart failure (HF) use administrative database sources, defining patient cohorts by presence of a single HF ICD code. However, the ability of ICD codes to identify true HF patients is unknown in pediatrics. Here we describe the accuracy of HF ICD-10-CM code search algorithms, in identifying pediatric patients with HF from electronic data sources.
Methods:
Based on the adult HF literature, search algorithms were designed to incorporate HF ICD codes, imaging, and medications. Sensitivity, specificity, positive and negative predictive value and accuracy of the algorithms were tested among children in an advanced HF clinic ("Clinic cohort"). Top-performing algorithms were then tested in a large-scale regional electronic data warehouse (EDW), 01/2017 to 01/2020, generating the "EDW Cohort". False positive cases were identified and characterized by chart review.
Results:
Within the Clinic Cohort, 78/378 patients (21%) had gold standard HF diagnoses. A search algorithm with one HF ICD coded visit was more sensitive but less specific than >1 HF ICD coded visit, (sensitivity 94% and specificity 89% versus 69% and 97%, respectively). Correspondingly, >1 ICD coded visit had a higher PPV than one ICD coded visit; 84% vs. 69%. Accuracy was similar (90% vs 91%). Presence of 1 HF ICD code combined with HF medication had high sensitivity, specificity, PPV, NPV and accuracy, all higher than the single ICD code algorithm. The "1 HF coded visit + any medication" algorithm resulted in highest accuracy (93%). Top-performing algorithms were tested in the EDW: the algorithm with > 1 HF ICD coded visit, and the algorithm with one HF ICD coded visit combined with HF medication. In the EDW Cohort, 133/248 (53.6%) patients had gold standard HF diagnoses though 115/248 (46.3%) were false positive cases; 41% of those had pulmonary over-circulation from congenital heart disease. Excluding children < 30 days old and those with a history of an isolated VSD repair, complete AVSD repair, or PDA closure further reduced the proportion of false positives to 50/248 (20%).
Conclusions:
A search algorithm using a single HF ICD code can have acceptable sensitivity, specificity, PPV, NPV and accuracy in identifying children with HF from within electronic medical records. Similar to adult HF literature, specificity improves by including HF medication. When applied to large data sources, however, the search algorithms result in a high proportion of patients with pulmonary overcirculation related to congenital heart disease. To narrow the population to those with myocardial dysfunction, case identification may require use of ICD codes with linked of administrative, surgical, and/or imaging databases.
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