American Heart Association

outcomes

Cracking ICD-9-CM Codes: Accuracy of Discharge Diagnoses in Stroke

Mark McAllister, MD


Jones SA, Gottesman RF, Shahar E, Wruck L, Rosamond WD. Validity of Hospital Discharge Diagnosis Codes for Stroke: The Atherosclerosis Risk in Communities Study. Stroke. 2014

Epidemiological estimates regarding stroke prevalence and mortality are often based on ICD-9-CM codes from hospital discharge. The accuracy of such statements is dependent on the codes actually corresponding to the labelled diagnosis. The authors sought to investigate the sensitivity and positive predictive values of ICD-9-CM codes for stroke and intracranial hemorrhage using diagnoses from the Atherosclerosis Risk in Communities (ARIC) study as the gold standard.


The ARIC study is comprised of nearly 16,000 patients in four communities in the US, and the database was searched for hospitalizations for ischemic strokes and intracranial hemorrhage. Strokes were identified by use of a stroke/hemorrhage related ICD-9-CM code, keywords in the discharge summary, or cerebral radiographic findings and validated by both computer algorithm and physician reviewer. Using this group of validated stroke and hemorrhage diagnoses the ICD-9-CM codes were compared.

Looking at AHA/ASA code groupings for ischemic stroke, intracerebral hemorrhage, and subarachnoid hemorrhage they found the positive predictive value to be 76% and sensitivity of 68%. An alternative grouping using more ICD codes increased sensitivity to 83%. These numbers are lower than previously published values and suggest stroke incidence may be underestimated based on ICD-9-CM codes.

10 years of experience with telestroke in Germany

Ali Saad, MD

Müller-Barna P, Hubert GJ, Boy S, Bogdahn U, Wiedmann S, Heuschmann PU, and Audebert HJ. TeleStroke Units Serving as a Model of Care in Rural Areas: 10-Year Experience of the TeleMedical Project for Integrative Stroke Care. Stroke. 2014

This paper presents data from the German telestroke network, TEMPiS (TeleMedical Project for integrative Stroke Care). Established in 2003, it provides remote stroke expertise to rural areas in Germany. They used prospective registries from TEMPiS hospitals from 2003-12 and looked at typical stroke metrics.


Key findings were
– percentage of patients seen in the hospital with stroke/TIA as the diagnosis 19%->78%
– thrombolytic administration 2.6%->15.5%,
– median onset to treatment time 150min->120min
– door to needle time 80min->40min

Limitations of the TEMPiS experience include the lack of data on sustainability due to its novelty. The data excludes in-hospital strokes, but included hemorrhagic strokes. Included patients were from the largest insurer in the area, but it only covers 40% of the population.

This treatment model is great for rural areas without access to large stroke centers as well as patients who prefer treatment at their local hospital. It also provides evidence that although stroke centers provide excellent care, telestroke is a cost-effective solution to rural areas who may not have the local expertise needed. The TEMPiS experience echoes the success of the telestroke networks in GA, USA and Alberta, CA.

The authors highlight the need to develop relationships with the surrounding community hospitals and convince them that telestroke will provide care that is reliable and beneficial to their patients. This might seem to go without saying, but one must keep in mind that these rural hospitals have been managing without this service for years. It takes great leadership and some charisma to convince a group of doctors to change the way they’ve been practicing for years and invest in a new system.