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Poorly Controlled Cardiovascular Risk Factors and ICD-9 codes
Submit responseWe appreciate the comments of Dr. Kennedy. We agree that it is difficult to accurately capture disease severity and control based on commonly used ICD-9 classifications. For this reason, we used ICD-9-CM codes, along with ambulatory blood pressure measurements, laboratory results and prescriptions to identify the presence of hypertension, dyslipidemia and diabetes mellitus, but not to grade their degree of severity or control. As described in the Appendix (Table 2), and in the Methods Section, we used actual ambulatory blood pressure measurements and laboratory results from the electronic records at Kaiser Permanente to define control and pharmacy records to identify medication intensification (1). Previous studies have documented the accuracy of the Kaiser Permanente clinical databases used in our study (2, 3). For example, diabetes diagnosis, myocardial infarction and stroke were all confirmed at chart review in 98%, 99% and 75% of cases, respectively, as described in our article (1). Although we cannot exclude some misclassifications in the identification of hypertension, dyslipidemia and diabetes mellitus, our diagnostic criteria are certainly more accurate than relying on the ICD-9 codes alone.
In our study, levels of control were determined using actual measurements and current clinical guidelines. As we found that measuring therapy modifications in response to poor control in a large population was feasible, future studies should examine whether giving feedback on this process of care measure to physicians may increase the levels of control (1). This kind of measurements also has limitations, but may provide a more accurate index of the quality of clinical care than relying solely on measures that examine the proportion of patients that are in defined control.
References
1. Rodondi N, Peng T, Karter AJ, et al. Therapy modifications in response to poorly controlled hypertension, dyslipidemia, and diabetes mellitus. Ann Intern Med. 2006;144(7):475-84.
2. Go AS, Hylek EM, Borowsky LH, Phillips KA, Selby JV, Singer DE. Warfarin use among ambulatory patients with nonvalvular atrial fibrillation: the anticoagulation and risk factors in atrial fibrillation (ATRIA) study. Ann Intern Med. 1999;131(12):927-34.
3. Karter AJ, Ferrara A, Liu JY, Moffet HH, Ackerson LM, Selby JV. Ethnic disparities in diabetic complications in an insured population. Jama. 2002;287(19):2519-27.
Conflict of Interest:
None declared
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"Poorly Controlled" is still "Controlled"
Submit responseTo the Editor: The article "Therapy Modifications in Response to Poorly Controlled Cardiovascular Risk Factors" ignores the reality that the International Classification of Disease, 9th Edition, Clinical Modification (ICD-9-CM) classifies patients with "poorly controlled" cardiovascular risk factors as "well controlled". (New Paragraph) Accordingly physicians using terminology like "poorly controlled" to describe their uncontrolled hyperglycemic, hypertensive, and hyperlipidemic patients must have their records coded as "well controlled" since ICD-9-CM requires strict interpration of physician diagnosis assignment. Similarly, patients with "hypertensive emergency" and "hypertensive crisis" will be coded as well controlled hypertension by ICD-9-CM unless the physician uses the official CDC-sanctioned terminology of "accelerated" or "malignant" hypertension to describe these patients. (New Paragraph) As a result, ICD-9-CM administrative databases measuring physician quality and resource consumption (e.g. Healthgrades, Solucient, APR-DRGs) misrepresent patient severity of illness and outcomes when physicians use these unofficial terms. (New Paragraph) Annals of Internal Medicine and other highly-regarded peer review journals should consider official disease nosology and classifications when editing an author's manuscript submitted for publications. Alternatively, the American College of Physician's appointed member to the Editorial Advisory Board of the Coding Clinic for ICD-9-CM may advocate for revisions of ICD-9-CM that better match physician vocabularies in their literature and day-to-day practices. Sincerely, James S. Kennedy, M.D., C.C.S.Conflict of Interest:
None declared