1. Improving State Hospital Discharge Data: Insight from a 19-State Analysis Bruce A Lawrence Harold B Weiss Ted R Miller lawrence@pire.org

2. E-coded 19-State Hospital Discharge Data Set, 1997 >50% of the US population

3. Coding Standards in 23 States

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

5. 88.1% E Coded >90% 85-89% 75-79% 65-70%

6. 5.1% E Coded As Other/ Unspecified 1.6%-2.9% 3.0%-4.9% 5.0-7.0% 11.9%

7. 230,000 cases where the principal diagnosis was not acute injury: 22.3% of all acute injuries Diagnosis description Most Common Conditions 0.5%Infectious/parasitic diseaseSepticemia 0.5%NeoplasmsLung cancer 1.3%Endocrine/nutrition/metabolic /immunity/blood Volume depletion Diabetes 4.1%Mental disordersMajor depression 0.6%Nervous system & sense organs Epilepsy Alzheimer's 3.4%Circulatory systemHeart failure Atrial fibrillation 2.2%Respiratory systemPneumonia

8. Diagnosis description Most Common Conditions 1.1%Digestive systemIntestinal obstruction 0.6%Genitourinary systemUrinary tract infection 0.4%Complications of pregnancy/childbirth Early or threatened labor 1.7%Skin & subcutaneous tissueCellulitis & abscess 1.8%Musculoskeletal system & connective tissue Pathological fracture

9. Diagnosis description Most Common Conditions 2.5%Symptoms, signs, ill-defined conditions Syncope & collapse 0.2%Adverse effectsAngioneurotic edema 0.4%Complications of surgical/medical care Mechanical complication of implant 0.9%Factors influencing health status Observation

10. 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

11. 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

12. 5 of 22 states had readmission tags or encrypted patient IDs: 4%-8% are readmits

13. 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

14. 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