Assessment of the coding accuracy of warfarin-related bleeding events. Issue 159 (November 2017) - Delate, Thomas
Abstract: Introduction: Using International Classification of Diseases, 9th edition (ICD-9) diagnosis codes to identify potential warfarin-related bleeding events from administrative datasets is highly efficient but may be prone to identifying non-events. The objective of this study was to evaluate the ability of bleeding-related ICD-9 codes to identify true bleeding events in patients who were receiving warfarin therapy at the time of hospitalization. Methods: This was a cross-sectional study conducted in an integrated healthcare delivery system. Anticoagulated patients aged ≥ 18 years and hospitalized between January 1, 2014 and March 31, 2014 were identified using administrative data queries. All hospitalizations were manually chart reviewed by a trained abstractor blinded to hospitalization diagnoses to assess for true bleeding events. Identification of the presence or lack of bleeding-related ICD-9 diagnosis code(s) for each hospitalization was then performed. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated for each ICD-9 code present. Results: There were 486 hospitalizations in 468 anticoagulated patients with 57 true bleeding events identified. Patients had a mean age of 73.4 years and 50% were female. For codes in the principal position, sensitivity, specificity, PPV, and NPV were 7.0%, 99.8%, 80.0%, and 89.0%, respectively. For codes in any position, sensitivity, specificity, PPV, and NPV were 94.7%, 90.9%, 58.1%, and 99.2%, respectively. For major bleeding, sensitivity, specificity, PPV, and NPV were 100%, 83.1%, 14.0%, and 100%, respectively. Conclusions: While the absence of a bleeding ICD-9 code reliably ruled-out hospitalization for warfarin-related bleeding, bleeding ICD-9 codes in the principal position were rarely used and undesirable false positive rates were identified when ICD-9 codes when recorded in any position and for major bleeding. Manual chart review is recommended to validate bleeding events from administrative data. Highlights: ICD-9 codes have been used to identify adverse events. ICD-9 bleeding codes may be prone to identifying non-events. ICD-9 bleeding codes need to be validated for accuracy in anticoagulated patients. Absence of a bleeding ICD-9 code reliably ruled-out hospitalization for bleeding. Unfortunately, ICD-9 bleeding codes had undesirable high false positive rates.