Date Published: June 5, 2019
Publisher: Public Library of Science
Author(s): Marion Fermaut, Arnaud Fauconnier, Aurélie Brossard, Jimmy Razafimamonjy, Xavier Fritel, Annie Serfaty, Manisha Nair.
Complicated ectopic pregnancies with severe bleeding (CEPSB) are life-threatening situations and should be considered maternal near-miss cases. Previous studies have found an association between severe maternal morbidity secondary to CEPSB and substandard care. Almost all women with CEPSB are hospitalized, generating administrative and medical records. The objective of this study was to propose a method to measure the validity of the hospital discharge database (HDD) to detect CEPSB among hospital stays in two gynecological units.
We included all hospital stays of women who were 18–45 years old and hospitalized for acute pelvic pain or/and metrorrhagia in the two hospitals. The HDD was compared to medical data (gold standard). Two algorithms constructed from the International Classification of Disease (ICD-10) and Common Classification of Medical Procedures (CCAM), were applied to the HDD: a “predefined algorithm” according to coding guidelines and a “pragmatic algorithm” based on coding practices. Sensitivity, specificity and positive likelihood-ratios were calculated. False negatives and positives were analyzed to describe coding practices.
Among 370 hospital stays included, 52 were classified as CEPSB cases. The “predefined algorithm” gave a sensitivity of 23.1% (95% CI: 11.6–34.5) and a specificity of 99.1% (95% CI: 98.0–100.0) to identify CEPSB. The “pragmatic algorithm” gave a sensitivity of 63.5% (95% CI: 50.4–76.5) and a specificity of 94.7% (95% CI: 92.2–97.5) to identify CEPSB. Coding errors (77.6%) were due to misuse of diagnosis codes and because complications were not coded.
HDD is not reliable enough to detect CEPSB due to incorrect coding practices. However, it could be an ideal tool to monitor quality of care if a culture in data quality assessment is developed to improve quality of medical information.
Ectopic pregnancies (EPs) account for approximately 2 to 3% of pregnancies each year [1–5]. Tubal rupture occurs in 22 to 34% of cases and often results in hemoperitoneum . The Eighth Report of the Confidential Enquiries into Maternal Deaths in the United Kingdom, covering the period from 2006 to 2008, estimated a fatality rate of 16.9 (95% CI 7.6–37.6) per 100 000 EPs . Furthermore, a study from the United States estimated EP to be the most common cause of mortality during the first trimester of pregnancy . Thus, complicated EPs with severe bleeding (CEPSB) are life-threatening situations and should be considered maternal near-miss cases. Reducing the incidence of complications of EP is a national public health goal in France as in other countries in the world [8–10].
A total of 385 hospital stays of patient, aged between 18 and 45 years old hospitalized for acute pelvic pain or/and metrorrhagia in 2012 were considered for inclusion. Fifteen of these (3.9%) had no medical records: nine from center A and six from center B and were excluded from analysis.
This validity study of HDDs to detect CEPSB highlights that HDD cannot currently be relied on to detect such cases. Nevertheless, the use of HDD could be a useful tool to identify near-miss cases and manage quality of care in gynecologic emergency units and services. The HDD approach to identify hospital stays for clinical audit should be adapted to take into account coding practices and data collection organization. Reliability of medical data must be improved with culture in medical information and data quality assessment among health care providers and health care systems.