Adapting a clinical comorbidity index for use with ICD-9-CM administrative databases

Objectives.This study attempts to develop a comprehensive set of comorbidity measures for use with large administrative inpatient datasets.Methods.The study involved clinical and empirical review of comorbidity measures, development of a framework that attempts to segregate comorbidities from other

https://czresearch.com/dropbox/Elixhauser_MedCare_1998v36p8.pdf

Comorbidity measures for use with administrative data.

Objectives:Implementation of the International Statistical Classification of Disease and Related Health Problems, 10th Revision (ICD-10) coding system presents challenges for using administrative data. Recognizing this, we conducted a multistep process to develop ICD-10 coding algorithms to define C

https://czresearch.com/dropbox/Quan_MedCare_2005v43p1130.pdf

Coding algorithms for defining comorbidities in ICD-9-CM and ICD-10 administrative data.

Importance There is limited information describing the presenting characteristics and outcomes of US patients requiring hospitalization for coronavirus disease 2019 (COVID-19). Objective To describe the clinical characteristics and outcomes of patients with COVID-19 hospitalized in a US health care system. Design, Setting, and Participants Case series of patients with COVID-19 admitted to 12 hospitals in New York City, Long Island, and Westchester County, New York, within the Northwell Health system. The study included all sequentially hospitalized patients between March 1, 2020, and April 4, 2020, inclusive of these dates. Exposures Confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection by positive result on polymerase chain reaction testing of a nasopharyngeal sample among patients requiring admission. Main Outcomes and Measures Clinical outcomes during hospitalization, such as invasive mechanical ventilation, kidney replacement therapy, and death. Demographics, baseline comorbidities, presenting vital signs, and test results were also collected. Results A total of 5700 patients were included (median age, 63 years [interquartile range {IQR}, 52-75; range, 0-107 years]; 39.7% female). The most common comorbidities were hypertension (3026; 56.6%), obesity (1737; 41.7%), and diabetes (1808; 33.8%). At triage, 30.7% of patients were febrile, 17.3% had a respiratory rate greater than 24 breaths/min, and 27.8% received supplemental oxygen. The rate of respiratory virus co-infection was 2.1%. Outcomes were assessed for 2634 patients who were discharged or had died at the study end point. During hospitalization, 373 patients (14.2%) (median age, 68 years [IQR, 56-78]; 33.5% female) were treated in the intensive care unit care, 320 (12.2%) received invasive mechanical ventilation, 81 (3.2%) were treated with kidney replacement therapy, and 553 (21%) died. As of April 4, 2020, for patients requiring mechanical ventilation (n = 1151, 20.2%), 38 (3.3%) were discharged alive, 282 (24.5%) died, and 831 (72.2%) remained in hospital. The median postdischarge follow-up time was 4.4 days (IQR, 2.2-9.3). A total of 45 patients (2.2%) were readmitted during the study period. The median time to readmission was 3 days (IQR, 1.0-4.5) for readmitted patients. Among the 3066 patients who remained hospitalized at the final study follow-up date (median age, 65 years [IQR, 54-75]), the median follow-up at time of censoring was 4.5 days (IQR, 2.4-8.1). Conclusions and Relevance This case series provides characteristics and early outcomes of sequentially hospitalized patients with confirmed COVID-19 in the New York City area.

https://jamanetwork.com/journals/jama/articlepdf/2765184/jama_richardson_2020_oi_200043.pdf

Presenting Characteristics, Comorbidities, and Outcomes Among 5700 Patients Hospitalized With COVID-19 in the New York City Area.

Validation of a combined comorbidity index.

A new method of classifying prognostic comorbidity in longitudinal studies: Development and validation☆

OBJECTIVE: To determine the independent contribution of admission delirium to hospital outcomes including mortality, institutionalization, and functional decline. DESIGN: Three prospective cohort studies. SETTING: Three university-affiliated teaching hospitals. PATIENTS: Consecutive samples of 727 patients, aged 65 years and older. MEASUREMENTS AND MAIN RESULTS: Delirum was present at admission in 88 (12%) of 727 patients. The main outcome measures at hospital discharge and 3-month follow-up were death, new nursing home placement, death or new nursing home placement, and functional decline. At hospital discharge, new nursing home placement occurred in 60 (9%) of 692 patients, and the adjusted odds ratio (OR) for delirium, controlling for baseline covariates of age, gender, dementia, APACHE II score, and functional measures, was 3.0, (95% confidence interval [CI] 1.4, 6.2). Death or new nursing home placement occurred in 95 (13%) of 727 patients (adjusted OR for delirium 2.1, 95% CI 1.1, 4.0). The findings were replicated across all sites. The associations between delirium and death alone (in 35 [5%] of 727 patients) and between delirium and length of stay were not statistically significant. At 3-month follow-up, new nursing home placement occurred in 77 (13%) of 600 patients (adjusted OR for delirium 3.0; 95% CI 1.5, 6.0). Death or new nursing home placement occurred in 165 (25%) of 663 patients (adjusted OR for delirium 2.6; 95% CI 1.4, 4.5). The findings were replicated across all sites. For death alone (in 98 [14%] of 680 patients), the adjusted OR for delirium was 1.6 (95% CI 0.8, 3.2). Delirium was a significant predictor of functional decline at both hospital discharge (adjusted OR 3.0; 95% CI 1.6, 5.8) and follow-up (adjusted OR 2.7; 95% CI 1.4, 5.2). CONCLUSIONS: Delirium is an important independent prognostic determinant of hospital outcomes including new nursing home placement, death or new nursing home placement, and functional decline—even after controlling for age, gender, dementia, illness severity, and functional status. Thus, delirium should be considered as a prognostic variable in case-mix adjustment systems and in studies examining hospital outcomes in older persons.

Does delirium contribute to poor hospital outcomes? A three-site epidemiologic study.

The purpose of this study was fourfold: to determine the rate of delirium among hospitalized older persons, to contrast the clinical outcomes of patients with and without delirium, to identify clinical predictors of delirium, and to validate the predictive model in an independent sample of patients.

Delirium in hospitalized older persons: outcomes and predictors.

Background: Delirium occurs commonly among older hospitalized patients and is frequently not recognized. In an effort to identify tools useful to clinicians in the diagnosis of delirium, test characteristics of four screening instruments were compared. Methods: Patients 65 years of age or older who were admitted to one of four medical and surgical wards of a university teaching hospital were followed up prospectively. Potential subjects were excluded if unavailable for interviews or discharged within 48 hours of admission, or if judged too impaired to participate in the daily interviews. Research assistants administered four instruments used to detect delirium: Digit Span Test, Vigilance 'A' Test, Clinical Assessment of Confusion, and Confusion Assessment Method. Abnormal scores on these tests or suspicion of acute confusion prompted a referral to the clinician-investigators who then assessed the patient daily for delirium based on the Diagnostic and Statistical Manual of Mental Disor- ders, Revised Third Edition criteria. Results: Delirium occurred in 64 (14.8%) of 432 subjects. The positive likelihood ratios for all of the instruments were significantly more than 1. The instruments remained useful when applied to selected subgroups: subjects in whom acute mental status changes were documented, subjects on surgical services, and subjects with impaired cognitive status on admission. Combinations of any two instruments did not perform substantially better than the instrument with the best test characteristics: the Clinical Assessment of Confusion. All instruments were more useful at confirming delirium than in excluding it. Conclusion: The four instruments studied, which are suitable for use at the bedside, can aid the clinician in identifying patients likely to be suffering from delirium. (Arch Intern Med. 1995;155:301-307)

Detecting Delirium Among Hospitalized Older Patients

Objectives: to determine the presentation, course and duration of delirium in hospitalized older people. Design: observational cohort study. Setting: inpatient surgical and medical wards at a university hospital. Participants: 432 people over the age of 65. Measurements: all participants were screened daily for confusion and, in those who were confused, delirium was ascertained using the Diagnostic and Statistical Manual of Mental Disorders (DSM) HI-R criteria. Those who were found to be delirious were followed daily while in hospital for evidence of delirium. The Delirium Rating Scale (DRS) was used to describe the clinical characteristics of delirium. Results: about 15% of subjects had delirium. Sixty-nine percent of delirious subjects had delirium on a single day. The DRS total was higher on the first day of delirium for those with delirium on multiple days than those with delirium on a single day (/• = 0.03). Among those with delirium on multiple days, there were no patterns of change over time in specific DRS items. Conclusions: delirium in hospitalized older people is common and has a varied presentation and time course. Clinicians and researchers need to consider this great heterogeneity when caring for patients and when studying delirium.

/pdf/the-natural-history-of-delirium-in-older-hospitalized-2m6yga9ojl.pdf

Peter Pompei

Papers

A new method of classifying prognostic comorbidity in longitudinal studies: Development and validation☆

Does delirium contribute to poor hospital outcomes? A three-site epidemiologic study.

Delirium in hospitalized older persons: outcomes and predictors.

Detecting Delirium Among Hospitalized Older Patients

The natural history of delirium in older hospitalized patients: a syndrome of heterogeneity.