Clinical and economic analysis of Gastrodin injection for dizziness or vertigo: a retrospective cohort study based on electronic health records in China

Background Dizziness and vertigo are common clinical symptoms. Gastrodin injection has shown clinical effects on dizziness or vertigo. However, little is known about the effectiveness and costs of combining Gastrodin injection with conventional treatment on dizziness or vertigo in daily practice. This study aimed to analyze the clinical and economic effects of Gastrodin injection for patients with dizziness or vertigo in comparison to Extract of Ginkgo Biloba Leaves injection in real-world practice. Methods Data was collected from the Hospital Information System of 131 hospitals across China from January to December 2018. Patients whose primary discharge diagnosis was dizziness or vertigo according to ICD-10 diagnostic coding were included and divided into two samples: sample of dizziness or vertigo; sample of dizziness or vertigo, with the complication of cerebral infarction. Comparative analysis of the medical cost per hospitalization, hospitalization duration, effective rates, and cure rates between the group of Gastrodin injection and the group of Extract of Ginkgo Biloba Leaves injection was conducted. Propensity Score Matching was used to control potential confounding factors. Results In the sample of dizziness or vertigo, although there was no significant differences on hospitalization duration (P = 0.080), the group of Gastrodin injection was significantly better than the group of Extract of Ginkgo Biloba Leaves injection (P < 0.001) in terms of treatment effect and the per capita hospitalization cost. In the sample of dizziness or vertigo, with the complication of cerebral infarction, there was no significant difference (P = 0.371) in terms of hospitalization duration, but the group of Gastrodin injection was significantly better than the group of Extract of Ginkgo Biloba Leaves injection (P = 0.009) in terms of treatment effect, and significant difference regarding the per capita hospitalization cost (P < 0.001). Conclusions Gastrodin injection showed advantages for inpatients with dizziness or vertigo compared with Extract of Ginkgo Biloba Leaves injection. Future studies using prospective pragmatic controlled trials can test and explore more about the effects of Gastrodin injections on dizziness or vertigo.

ICD-10 Diagnostic Coding for Identifying Hospitalizations Related to a Diabetic Foot Ulcer

Purpose: To estimate the positive predictive value (PPV) of Canadian ICD-10 diagnostic coding for the identification of hospitalization related to a diabetic foot ulcer (DFU). Methods: Hospitalizations related to a neuropathic and/or ischemic DFU were identified from the Discharge Abstract Database (DAD) records of a single Canadian tertiary care hospital between April 1, 2002 and March 31, 2019. The first coding approach required a most responsible diagnosis (MRDx) code for diabetes-specific foot ulceration or gangrene (DSFUG group). Three alternative coding approaches were also considered: MRDx code for lower-limb osteomyelitis (osteomyelitis group); lower-limb ulceration (LLU group); or lower-limb atherosclerotic gangrene (atherosclerosis group)—each in conjunction with a non-MRDx DSFUG code on the same DAD record. From all eligible DAD records, random samples were drawn for each coding group. DAD records were independently compared by a masked reviewer who manually abstracted data from the entire hospital record (reference standard). The PPV and 95% CI were generated. Results: Out of 1,460 hospitalizations, a total of 300, 50, 33 and seven records were included from the DSFUG, osteomyelitis, LLU and atherosclerosis samples, respectively. Compared to the reference standard, the PPV for all 390 records was 88.5% (95% CI 84.9 to 91.5). The DSFUG group had the highest PPV (90.0%, 95% CI 86.0 to 93.2), followed by the atherosclerosis (85.7%, 95% CI 42.1 to 99.6), LLU (84.9%, 95% CI 68.1 to 94.9) and osteomyelitis (82.0%, 95% CI 68.6 to 91.4) groups. Conclusion: Based on data from a Canadian tertiary care hospital, the specified coding algorithms can be used to identify and study the management and outcomes of people hospitalized with a DFU in Ontario.

Association of cerebral venous thrombosis with recent COVID-19 vaccination: case-crossover study using ascertainment through neuroimaging in Scotland

Background To investigate the association of primary acute cerebral venous thrombosis (CVT) with COVID-19 vaccination through complete ascertainment of all diagnosed CVT in the population of Scotland. Methods Case-crossover study comparing cases of CVT recently exposed to vaccination (1–14 days after vaccination) with cases less recently exposed. Cases in Scotland from 1 December 2020 were ascertained through neuroimaging studies up to 17 May 2021 and diagnostic coding of hospital discharges up to 28 April 2021, linked to national vaccination records. The main outcome measure was primary acute CVT. Results Of 50 primary acute CVT cases, 29 were ascertained only from neuroimaging studies, 2 were ascertained only from hospital discharges, and 19 were ascertained from both sources. Of these 50 cases, 14 had received the Astra-Zeneca ChAdOx1 vaccine and 3 the Pfizer BNT162b2 vaccine. The incidence of CVT per million doses in the first 14 days after vaccination was 2.2 (95% credible interval 0.9 to 4.1) for ChAdOx1 and 1 (95% credible interval 0.1 to 2.9) for BNT162b2. The rate ratio for CVT associated with exposure to ChAdOx1 in the first 14 days compared with exposure 15-84 days after vaccination was 3.2 (95% credible interval 1.1 to 9.5). Conclusions These findings support a causal association between CVT and the AstraZeneca vaccine. The absolute risk of post-vaccination CVT in this population-wide study in Scotland was lower than has been reported for populations in Scandinavia and Germany; the explanation for this is not clear.

Decomposition of outpatient health care spending by disease - a novel approach using insurance claims data

Background Decomposing health care spending by disease, type of care, age, and sex can lead to a better understanding of the drivers of health care spending. But the lack of diagnostic coding in outpatient care often precludes a decomposition by disease. Yet, health insurance claims data hold a variety of diagnostic clues that may be used to identify diseases. Methods In this study, we decompose total outpatient care spending in Switzerland by age, sex, service type, and 42 exhaustive and mutually exclusive diseases according to the Global Burden of Disease classification. Using data of a large health insurance provider, we identify diseases based on diagnostic clues. These clues include type of medication, inpatient treatment, physician specialization, and disease specific outpatient treatments and examinations. We determine disease-specific spending by direct (clues-based) and indirect (regression-based) spending assignment. Results Our results suggest a high precision of disease identification for many diseases. Overall, 81% of outpatient spending can be assigned to diseases, mostly based on indirect assignment using regression. Outpatient spending is highest for musculoskeletal disorders (19.2%), followed by mental and substance use disorders (12.0%), sense organ diseases (8.7%) and cardiovascular diseases (8.6%). Neoplasms account for 7.3% of outpatient spending. Conclusions Our study shows the potential of health insurance claims data in identifying diseases when no diagnostic coding is available. These disease-specific spending estimates may inform Swiss health policies in cost containment and priority setting.

Red Cell Alloimmunization Is Associated with Higher Treatment Costs and Poor Health Outcomes Among Hemoglobin S-Beta Thalassemia Patients

Hemoglobin S (HbS) beta thalassemias (thal) are types of sickle cell disease (SCD) that result from the inheritance of one HbS gene and one β thalassemia gene. Red Blood Cell (RBC) alloimmunization is believed to be a major complication of transfusion therapy for HbS-thal patients. Indeed, among SCD patients generally, alloimmunization not only complicates the procurement of blood, but can also lead to life threatening delayed hemolytic transfusion reactions, and can be associated with a host of negative health outcomes including a higher risk of death. It is generally accepted that some alloimmunization events can be prevented via donor-recipient antigen matching, although this strategy is associated with higher costs and utilization of scarce resources (i.e.. antigen negative RBC units). The present study aimed to assess the clinical and economic implications of alloimmunization in HbS-thal patients. The Premier Hospital chargemaster dataset was used to perform a cross-sectional study matching alloimmunized and non-alloimmunized patients based on sex, age, date of admission, and type of visit (outpatient vs. inpatient). All outpatient and inpatient discharges from Jan 2015 to Jun 2019 were included in the study. Because there is not a specific laboratory code to designate alloimmunization, presence of both "antiglobulin crossmatch" and "RBC antibody identification" codes in a record was used as a surrogate for alloimmunization. Accuracy of this approach was validated by comparing the frequency of these codes among the hereditary hemorrhagic telangiectasia (HHT) and myelodysplastic syndromes (MDS) populations within the Premier dataset to the reported rates of alloimmunization for these entities in the medical literature (Zheng Transfusion. 2018;58(3):775-780, Singhal Haematologica. 2017;102(12):2021-2029). This comparison predicted a 16.8% alloimmunization rate in the HHT population (similar to the 15.3% reported in the literature) and an 11.5% alloimmunization prevalence in the MDS population (similar to the 11% reported in the literature). HbS-thal patients were identified based on diagnostic coding (ICD-10 code D57.4). Demographic, clinical and billing characteristics were retrieved. Cost per outpatient and inpatient discharge, hospital and intensive care unit (ICU) length of stay (LoS) and inpatient mortality were assessed for both alloimmunized and non-alloimmunized HbS-thal patients. Bivariate comparisons were performed, assuming a two-tailed test of significance and an α level of 0.05. Multivariable regression models adjusting for diagnosis-related groups with ≥1% incidence were performed. This approach permitted a total of 999 discharges corresponding to alloimmunized HbS-thal patients (cases) to be matched to 550 HbS-thal controls. Mean (SD) age was 35.1 (18.8) and 30.1 (18.6) for cases and controls, respectively. The percentage of females was slightly higher within the alloimmunized group (63.66% vs. 57.45%), and higher rates of inpatient visits were observed for the alloimmunized population compared to controls (67.9% vs. 33.1%). The multivariate models showed that alloimmunized HbS-thal patients presented significantly worse economic and clinical outcomes compared to their non-alloimmunized controls through all variables assessed. Median cost per discharge was $5,313 (p&lt;0.0001) higher for alloimmunized inpatients and $1,014 (p&lt;0.0001) higher for alloimmunized outpatients, compared to non-alloimmunized controls. Alloimmunized HbS-thal patients also experienced a 63% increase in hospital LoS (4.5 vs 7.4 days;; p&lt;0.0001) and nearly over a 2.5-fold increase in ICU LoS (4.2 vs 10.0 days; p=0.0257). Alloimmunization in this population was also associated with a 3-fold increased risk of admission to intensive care (p=0.0032), longer stays in the ICU (p-0.0257), and a 3-fold increase in inpatient death (p&lt;0.0001) (Table 1). The present study reveals that alloimmunization is associated with significantly longer hospitalizations and ICU stays, higher risk of ICU admission, greater inpatient death, and higher healthcare costs among patients with ICD-10 diagnosis of HbS-thal. These data seem to support the incremental costs and resource allocation decisions required to provide prophylactic antigen matching to HbS-thal patients, in an effort to diminish the risk of alloimmunization. Figure 1 Figure 1. Disclosures Gehrie: Grifols SSNA: Consultancy, Honoraria. Viayna: Grifols S.A.: Current Employment. Blanchette: Grifols SSNA: Consultancy; Novo Nordisk Inc.: Current Employment. Meny: Grifols SSNA: Current Employment. Noumsi: Grifols SSNA: Current Employment. Huber: Grifols SSNA: Current Employment. Runken: Grifols SSNA: Current Employment.

Effects of preoperative physiotherapy on signs and symptoms of pulmonary collapse and infection after major abdominal surgery: secondary analysis of the LIPPSMAck-POP multicentre randomised controlled trial

Background Preoperative education and breathing exercise training by a physiotherapist minimises pulmonary complications after abdominal surgery. Effects on specific clinical outcomes such as antibiotic prescriptions, chest imaging, sputum cultures, oxygen requirements, and diagnostic coding are unknown. Methods This post hoc analysis of prospectively collected data within a double-blinded, multicentre, randomised controlled trial involving 432 participants having major abdominal surgery explored effects of preoperative education and breathing exercise training with a physiotherapist on postoperative antibiotic prescriptions, hypoxemia, sputum cultures, chest imaging, auscultation, leukocytosis, pyrexia, oxygen therapy, and diagnostic coding, compared to a control group who received a booklet alone. All participants received standardised postoperative early ambulation. Outcomes were assessed daily for 14 postoperative days. Analyses were intention-to-treat using adjusted generalised multivariate linear regression. Results Preoperative physiotherapy was associated with fewer antibiotic prescriptions specific for a respiratory infection (RR 0.52; 95% CI 0.31 to 0.85, p = 0.01), less purulent sputum on the third and fourth postoperative days (RR 0.50; 95% CI 0.34 to 0.73, p = 0.01), fewer positive sputum cultures from the third to fifth postoperative day (RR 0.17; 95% CI 0.04 to 0.77, p = 0.01), and less oxygen therapy requirements (RR 0.49; 95% CI 0.31 to 0.78, p = 0.002). Treatment effects were specific to respiratory clinical coding domains. Conclusions Preoperative physiotherapy prevents postoperative pulmonary complications and is associated with the minimisation of signs and symptoms of pulmonary collapse/consolidation and airway infection and specifically results in reduced oxygen therapy requirements and antibiotic prescriptions. Trial registration ANZCTR 12613000664741; 19/06/2013.

Predicting diagnostic coding in hospitals: individual level effects of price incentives

The purpose of this paper is to test if implicit price incentives influence the diagnostic coding of hospital discharges. We estimate if the probability of being coded as a complicated patient was related to a specific price incentive. This paper tests empirically if upcoding can be linked to shifts in patient composition through proxy measures such as age composition, length of stay, readmission rates, mortality- and morbidity of patients. Data about inpatient episodes in Norway in all specialized hospitals in the years 1999–2012 were collected, N = 11 065 330. We examined incentives present in part of the hospital funding system. First, we analyse trends in the proxy measures of diagnostic upcoding: can hospital behavioural changes be seen over time with regards to age composition, readmission rates, length of stay, comorbidity and mortality? Secondly, we examine specific patient groups to see if variations in the price incentive are related to probability of being coded as complicated. In the first years (1999–2003) there was an observed increase in the share of episodes coded as complicated, while the level has become more stable in the years 2004–2012. The analysis showed some indications of upcoding. However, we found no evidence of widespread upcoding fuelled by implicit price incentive, as other issues such as patient characteristics seem to be more important than the price differences. This study adds to previous research by testing individual level predictions. The added value of such analysis is to have better case mix control. We observe the presence of price effects even at individual level.

Diagnostic coding of chronic physical conditions in Irish general practice

Background Chronic conditions are responsible for significant mortality and morbidity among the population in Ireland. It is estimated that almost one million people are affected by one of the four main categories of chronic disease (cardiovascular disease, chronic obstructive pulmonary disease, asthma, and diabetes). Primary healthcare is an essential cornerstone for individuals, families, and the community and, as such, should play a central role in all aspects of chronic disease management. Aim The aim of the project was to examine the extent of chronic disease coding of four chronic physical conditions in the general practice setting. Methods The design was a descriptive cross-sectional study with anonymous retrospective data extracted from practices. Results Overall, 8.8% of the adult population in the six participating practices were coded with at least one chronic condition. Only 0.7% of adult patients were coded with asthma, 0.3% with COPD, 3% with diabetes, and 3.3% with CVD. Male patients who visited their GP in the last year were more likely to be coded with any of the four chronic diseases in comparison with female patients. A significant relationship between gender and being coded with diabetes and CVD was found. Conclusions For a likely multitude of reasons, diagnostic coding in Irish general practice clinics in this study is low and insufficient for an accurate estimation of chronic disease prevalence. Monitoring of information provided through diagnostic coding is important for patients’ care and safety, and therefore appropriate training and reimbursement for these services is essential.

Elucidating the association between regional variation in diagnostic frequency with risk-adjusted mortality through analysis of claims data of medicare inpatients: a cross-sectional study

ObjectiveThe validity of risk-adjustment methods based on administrative data has been questioned because hospital referral regions with higher diagnosis frequencies report lower case-fatality rates, implying that diagnoses do not track the underlying health risk. The objective of this study is to test the hypothesis that regional variation of diagnostic frequency in inpatient records is not associated with different coding practices but a reflection of the underlying health risks.DesignWe applied two stratification methods to Medicare Analysis and Provider Review data from 2009 through 2014: (1) the number of chronic conditions; and, (2) quartiles of Risk Stratification Index (RSI)-defined risk. After sorting hospital referral regions into quintiles of diagnostic frequency, we examined all-cause mortality.SettingMedicare Analysis and Provider Review administrative database.Participants18 126 301 hospitalised Medicare fee-for-service beneficiaries aged 65 or older who had at least one hospital-based procedure between 2009 and 2014.ExposureCoding frequency and baseline regional population risk factors by hospital referral region.Primary and secondary outcome(s) and measure(s)One year all-cause mortality in patients having the same number of chronic conditions or within the same RSI score quartile across US health referral regions, grouped by diagnostic frequency.ResultsNo consistent relationship between diagnostic frequency and mortality in the risk stratum defined by number of chronic conditions was detected. In the strata defined by RSI quartile, there was no decrease in mortality as a function of diagnostic frequency. Instead, adjusted mortality was positively correlated with socioeconomic risk factors.ConclusionsUsing present-on-admission codes only, diagnostic frequency among inpatients with at least one hospital-based procedure appears to be consequent to differences in baseline population health status, rather than diagnostic coding practices. In this population, claims-based risk-adjustment using RSI appears to be useful for assessing hospital outcomes and performance.

Variation in waiting times by diagnostic category: an observational study of 1,951 referrals to a neurology outpatient clinic

ObjectiveTo investigate the frequency of diagnoses seen among new referrals to neurology outpatient services; to understand how these services are used through exploratory analysis of diagnostic tests and follow-up appointments; and to examine the waiting times between referral and appointment.MethodsRoutine data from new National Health Service appointments at a single consultant-delivered clinic between September 2016 and January 2019 were collected. These clinical data were then linked to hospital administrative data. The combined data were assigned diagnostic categories based on working diagnoses to allow further analysis using descriptive statistics.ResultsFive diagnostic categories accounted for 62% of all patients seen within the study period, the most common of which was headache disorders. Following a first appointment, 50% of all patients were offered at least one diagnostic test, and 35% were offered a follow-up appointment, with variation in both measures by diagnostic category. Waiting times from referral to appointment also varied by diagnostic category. 65% of patients with a seizure/epilepsy disorder were seen within the 18-week referral to treatment target, compared with 38% of patients with a movement disorder.ConclusionsA small number of diagnostic categories account for a large proportion of new patients. This information could be used in policy decision-making to describe a minimum subset of categories for diagnostic coding. We found significant differences in waiting times by diagnostic category, as well as tests ordered, and follow-up offered; further investigation could address causes of variation.