Improving State Hospital Discharge Data: Insight from a

19-State Analysis

Bruce A LawrenceHarold B Weiss

Ted R Millerlawrence@pire.org

E-coded 19-State Hospital Discharge Data Set, 1997

>50% of the US population

Coding Standards in 23 States

Not AvailableNon-standard

Format

Admit Type 3 4

Admit Source 2 4DischargeStatus

3

Race 5 4 many missing

Payer 23

Hospital ID: keyfor cleaning

4

Intensively Cleaned Dxs & E Codes

• 17.7 M discharges

• Selected injuries by Dx or E code

• 6.8% (1.21 M) injury discharges

• Dropped late effects & rehab admits

• 1.13 M acute injury discharges

• 93.4% of injuries were acute: ranged from 90% in NH & WA to 96% in NJ

88.1% E Coded

>90%85-89%75-79%65-70%

5.1% E Coded As Other/ Unspecified

1.6%-2.9%3.0%-4.9%5.0-7.0%11.9%

230,000 cases where the principal diagnosis was not acute injury: 22.3% of all acute injuries

Diagnosis descriptionMost Common Conditions

0.5% Infectious/parasitic disease Septicemia

0.5% Neoplasms Lung cancer

1.3% Endocrine/nutrition/metabolic/immunity/blood

Volume depletionDiabetes

4.1% Mental disorders Major depression

0.6% Nervous system & sense organs

EpilepsyAlzheimer's

3.4% Circulatory system Heart failureAtrial fibrillation

2.2% Respiratory system Pneumonia

Diagnosis descriptionMost Common Conditions

1.1% Digestive system Intestinal obstruction

0.6% Genitourinary system Urinary tract infection

0.4% Complications of pregnancy/childbirth

Early or threatened labor

1.7% Skin & subcutaneous tissue Cellulitis & abscess

1.8% Musculoskeletal system & connective tissue

Pathological fracture

Diagnosis descriptionMost Common Conditions

2.5% Symptoms, signs, ill-defined conditions

Syncope & collapse

0.2% Adverse effects Angioneurotic edema

0.4% Complications of surgical/medical care

Mechanical complication of implant

0.9% Factors influencing health status

Observation

Searched All Fields for a Valid Primary Injury Diagnosis

• Primary injury diagnosis is generally of good quality• 98.1% specific, including just 2.7% not in

the 800-995 range• 1.1% other/unspecified• 0.8% E code but no injury Dx• 4.1%-4.4% E code but no injury Dx in UT &

VA; 20% self-inflicted

Common Data Problems• Invalid Dxs & E codes

- Isolated typos

- Systematic facility-specific miscoding• Misuse of E codes

- Falls that do not cause treated injury

- Overexertion for heart/respiratory conditions

- Intracranial hemorrhage coded as illness to increase reimbursement

• Inconsistency between Dx & E codes for substances involved in poisoning

• Duplicate records: the old record is not deleted when a record is updated/corrected

5 of 22 states had readmission tags or encrypted patient IDs:

4%-8% are readmits

MO 1994 8.4% readmits

MI 5.2% readmits82.8% missing

NJ 6.3% readmits42.8% missing

VT 3.8% readmits

CA Not analyzed

Conclusion• Need to clean state HDS data & related

HCUP National Inpatient Sample injury data before using them: hard w/o hospital IDs - major HCUP NIS limitation

• Other/unspecified E codes or E codes w/o injury Dxs are problems in some states

• 6.6% of injury discharges are late effects or rehab

• 4%-8% of acute injury discharges are readmissions

• The principal Dx field codes a complication rather than the underlying injury in 17-22% of cases. We advise scanning 3 Dxs + E codes to identify injury discharges. A study is needed to see if cases with complications codes listed first have bad long-term outcome

• Only 2.7% of E-coded cases had primary injury Dxs below 800. These typically were back injury, cellulitis & abscess, maternal injury, coma, or anoxic brain damage.

• Need standardized US codes for payer type

• States need to adopt the standard codes that have been established