Katherine E Nelson1, Vishakha Chakravarti2, Catherine Diskin3, Joanna Thomson4, Eyal Cohen5, Sanjay Mahant6, Chris Feudtner7, Kimberley Widger8, Eleanor Pullenayegum9, Jay G Berry10, James A Feinstein11. 1. Pediatric Advanced Care Team, Hospital for Sick Children (KE Nelson, V Chakravarti, and K Widger), Toronto, Ontario, Canada; Division of Paediatric Medicine, Department of Paediatrics, Hospital for Sick Children (KE Nelson, C Diskin, E Cohen, and S Mahant), Toronto, Ontario, Canada; Child Health Evaluative Sciences, SickKids Research Institute (KE Nelson, V Chakravarti, E Cohen, S Mahant, and E Pullenayegum), Toronto, Ontario, Canada; Institute for Clinical Evaluative Sciences (KE Nelson, E Cohen, and S Mahant), Toronto, Ontario, Canada; Institute for Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto (KE Nelson, E Cohen, S Mahant, and E Pullenayegum), Toronto, Ontario, Canada. Electronic address: kate.nelson@sickkids.ca. 2. Pediatric Advanced Care Team, Hospital for Sick Children (KE Nelson, V Chakravarti, and K Widger), Toronto, Ontario, Canada; Child Health Evaluative Sciences, SickKids Research Institute (KE Nelson, V Chakravarti, E Cohen, S Mahant, and E Pullenayegum), Toronto, Ontario, Canada. 3. Division of Paediatric Medicine, Department of Paediatrics, Hospital for Sick Children (KE Nelson, C Diskin, E Cohen, and S Mahant), Toronto, Ontario, Canada. 4. Department of Pediatrics, University of Cincinnati College of Medicine (J Thomson), Cincinnati, Ohio; Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center (J Thomson), Cincinnati, Ohio. 5. Division of Paediatric Medicine, Department of Paediatrics, Hospital for Sick Children (KE Nelson, C Diskin, E Cohen, and S Mahant), Toronto, Ontario, Canada; Child Health Evaluative Sciences, SickKids Research Institute (KE Nelson, V Chakravarti, E Cohen, S Mahant, and E Pullenayegum), Toronto, Ontario, Canada; Institute for Clinical Evaluative Sciences (KE Nelson, E Cohen, and S Mahant), Toronto, Ontario, Canada; Institute for Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto (KE Nelson, E Cohen, S Mahant, and E Pullenayegum), Toronto, Ontario, Canada; CanChild Centre for Childhood Disability Research, McMaster University (E Cohen and S Mahant), Hamilton, Ontario, Canada; Edwin S.H. Leong Centre for Healthy Children, University of Toronto (E Cohen), Toronto, Ontario, Canada. 6. Division of Paediatric Medicine, Department of Paediatrics, Hospital for Sick Children (KE Nelson, C Diskin, E Cohen, and S Mahant), Toronto, Ontario, Canada; Child Health Evaluative Sciences, SickKids Research Institute (KE Nelson, V Chakravarti, E Cohen, S Mahant, and E Pullenayegum), Toronto, Ontario, Canada; Institute for Clinical Evaluative Sciences (KE Nelson, E Cohen, and S Mahant), Toronto, Ontario, Canada; Institute for Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto (KE Nelson, E Cohen, S Mahant, and E Pullenayegum), Toronto, Ontario, Canada; CanChild Centre for Childhood Disability Research, McMaster University (E Cohen and S Mahant), Hamilton, Ontario, Canada. 7. The Justin Michael Ingerman Center for Palliative Care, Children's Hospital of Philadelphia (C Feudtner), Philadelphia, Pa; Departments of Pediatrics and Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania (C Feudtner), Philadelphia, Pa. 8. Pediatric Advanced Care Team, Hospital for Sick Children (KE Nelson, V Chakravarti, and K Widger), Toronto, Ontario, Canada; Lawrence S. Bloomberg Faculty of Nursing, University of Toronto (K Widger), Toronto, Ontario, Canada. 9. Child Health Evaluative Sciences, SickKids Research Institute (KE Nelson, V Chakravarti, E Cohen, S Mahant, and E Pullenayegum), Toronto, Ontario, Canada; Institute for Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto (KE Nelson, E Cohen, S Mahant, and E Pullenayegum), Toronto, Ontario, Canada. 10. Complex Care, Division of General Pediatrics, Children's Hospital Boston (JG Berry), Boston, Mass; Department of Pediatrics, Harvard Medical School (JG Berry), Boston, Mass. 11. Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado and Children's Hospital Colorado (JA Feinstein), Aurora, Colo.
Abstract
OBJECTIVE: To assess the performance of previously published high-intensity neurologic impairment (NI) diagnosis codes in identification of hospitalized children with clinical NI. METHODS: Retrospective study of 500 randomly selected discharges in 2019 from a freestanding children's hospital. All charts were reviewed for 1) NI discharge diagnosis codes and 2) documentation of clinical NI (a neurologic diagnosis and indication of functional impairment like medical technology). Test statistics of clinical NI were calculated for discharges with and without an NI diagnosis code. A sensitivity analysis varied the threshold for "substantial functional impairment." Secondary analyses evaluated misclassified discharges and a more stringent definition for NI. RESULTS: Diagnosis codes identified clinically documented NI with 88.1% (95% confidence interval [CI]: 84.7, 91) specificity, and 79.4% (95% CI: 67.3, 88.5) sensitivity; negative predictive value (NPV) was 96.7% (95% CI: 94.8, 98.0), and positive predictive value (PPV) was 49% (95% CI: 42, 56.1). Including children with milder functional impairment (lower threshold) resulted in NPV of 95.7% and PPV of 77.5%. Restricting to children with more severe functional impairment (higher threshold) resulted in NPV of 98.2% and PPV of 44.1%. Misclassification was primarily due to inclusion of children without functional impairments. A more stringent NI definition including diagnosis codes for NI and feeding tubes had a specificity of 98.4% (95% CI: 96.7-99.3) and sensitivity of 28.6% (19.4-41.3). CONCLUSIONS: All scenarios evaluated demonstrated high NPV and low-to-moderate PPV of the diagnostic code list. To maximize clinical utility, NI diagnosis codes should be used with strategies to mitigate the risk of misclassification.
OBJECTIVE: To assess the performance of previously published high-intensity neurologic impairment (NI) diagnosis codes in identification of hospitalized children with clinical NI. METHODS: Retrospective study of 500 randomly selected discharges in 2019 from a freestanding children's hospital. All charts were reviewed for 1) NI discharge diagnosis codes and 2) documentation of clinical NI (a neurologic diagnosis and indication of functional impairment like medical technology). Test statistics of clinical NI were calculated for discharges with and without an NI diagnosis code. A sensitivity analysis varied the threshold for "substantial functional impairment." Secondary analyses evaluated misclassified discharges and a more stringent definition for NI. RESULTS: Diagnosis codes identified clinically documented NI with 88.1% (95% confidence interval [CI]: 84.7, 91) specificity, and 79.4% (95% CI: 67.3, 88.5) sensitivity; negative predictive value (NPV) was 96.7% (95% CI: 94.8, 98.0), and positive predictive value (PPV) was 49% (95% CI: 42, 56.1). Including children with milder functional impairment (lower threshold) resulted in NPV of 95.7% and PPV of 77.5%. Restricting to children with more severe functional impairment (higher threshold) resulted in NPV of 98.2% and PPV of 44.1%. Misclassification was primarily due to inclusion of children without functional impairments. A more stringent NI definition including diagnosis codes for NI and feeding tubes had a specificity of 98.4% (95% CI: 96.7-99.3) and sensitivity of 28.6% (19.4-41.3). CONCLUSIONS: All scenarios evaluated demonstrated high NPV and low-to-moderate PPV of the diagnostic code list. To maximize clinical utility, NI diagnosis codes should be used with strategies to mitigate the risk of misclassification.
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