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Original Research |

Variation in Diagnostic Coding of Patients With Pneumonia and Its Association With Hospital Risk-Standardized Mortality Rates: A Cross-sectional Analysis

Michael B. Rothberg, MD, MPH; Penelope S. Pekow, PhD; Aruna Priya, MA, MSc; and Peter K. Lindenauer, MD, MSc
[+] Article and Author Information

From Medicine Institute, Cleveland Clinic, Cleveland, Ohio; Center for Quality of Care Research, Baystate Medical Center, Springfield, Massachusetts; Tufts University School of Medicine, Boston, Massachusetts; and University of Massachusetts, Amherst, Massachusetts.

Grant Support: By the Agency for Healthcare Research and Quality (R01HS018723).

Potential Conflicts of Interest: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M13-1419.

Reproducible Research Statement: Study protocol: Available from Dr. Rothberg (e-mail, rothbem@ccf.org). Statistical code: Available from Dr. Pekow (e-mail, penelope.pekow@bhs.org). Data set: Not available.

Requests for Single Reprints: Michael B. Rothberg, MD, MPH, Department of Medicine, Medicine Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195; e-mail, rothbem@ccf.org.

Current Author Addresses: Dr. Rothberg: Department of Medicine, Medicine Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195.

Drs. Pekow and Lindenauer and Ms. Priya: Center for Quality of Care Research, Baystate Medical Center, 280 Chestnut Street, Third Floor, Springfield, MA 01199.

Author Contributions: Conception and design: M.B. Rothberg, P.K. Lindenauer.

Analysis and interpretation of the data: M.B. Rothberg, P.S. Pekow, A. Priya, P.K. Lindenauer.

Drafting of the article: M.B. Rothberg.

Critical revision of the article for important intellectual content: M.B. Rothberg, P.S. Pekow, A. Priya, P.K. Lindenauer.

Final approval of the article: M.B. Rothberg, P.S. Pekow, A. Priya, P.K. Lindenauer.

Provision of study materials or patients: M.B. Rothberg.

Statistical expertise: P.S. Pekow, A. Priya.

Obtaining of funding: M.B. Rothberg.

Administrative, technical, or logistic support: M.B. Rothberg, P.S. Pekow, P.K. Lindenauer.

Collection and assembly of data: M.B. Rothberg, P.S. Pekow, A. Priya, P.K. Lindenauer


Ann Intern Med. 2014;160(6):380-388. doi:10.7326/M13-1419
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Background: Most U.S. hospitals publicly report 30-day risk-standardized mortality rates for pneumonia. Rates exclude severe cases, which may be assigned a secondary diagnosis of pneumonia and a principal diagnosis of sepsis or respiratory failure. By assigning sepsis and respiratory failure codes more liberally, hospitals might improve their reported performance.

Objective: To examine the effect of the definition of pneumonia on hospital mortality rates.

Design: Cross-sectional study.

Setting: 329 U.S. hospitals.

Patients: Adults hospitalized for pneumonia (as a principal diagnosis or secondary diagnosis paired with a principal diagnosis of sepsis or respiratory failure) between 2007 and 2010.

Measurements: Proportion of patients with pneumonia coded with a principal diagnosis of sepsis or respiratory failure and risk-standardized mortality rates excluding versus including a principal diagnosis of sepsis or respiratory failure.

Results: When the definition of pneumonia was limited to patients with a principal diagnosis of pneumonia, the risk-standardized mortality rate was significantly better than the mean in 4.3% of hospitals and significantly worse in 6.4%. When the definition was broadened to include patients with a principal diagnosis of sepsis or respiratory failure, this rate was better than the mean in 11.9% of hospitals and worse in 22.8% and the outlier status of 28.3% of hospitals changed. Among hospitals in the highest quintile of proportion of patients coded with a principal diagnosis of sepsis or respiratory failure, outlier status under the broader definition improved in 7.6% and worsened in 40.9%. Among those in the lowest quintile, 20.0% improved and none worsened.

Limitation: Only inpatient mortality was studied.

Conclusion: Variation in use of the principal diagnosis of sepsis or respiratory failure may bias efforts to compare hospital performance regarding pneumonia outcomes.

Primary Funding Source: Agency for Healthcare Research and Quality.

Figures

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Figure 1.

Variation in hospital rate of coding a principal diagnosis of sepsis/respiratory failure among patients with pneumonia.

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Figure 2.

Hospital pneumonia mortality rates and proportion of pneumonia cases with a principal diagnosis of sepsis/respiratory failure.

Hospitals are divided into 2 equal groups at the median proportion of sepsis/respiratory failure cases.

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Figure 3.

Early admission to the ICU or treatment with invasive mechanical ventilation or vasopressors among patients with pneumonia and a principal diagnosis of sepsis/respiratory failure.

ICU = intensive care unit.

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Figure 4.

Risk-standardized mortality rates for each hospital including or excluding patients with a principal diagnosis of sepsis/respiratory failure.

The vertical line represents the mean risk-standardized mortality rate excluding sepsis/respiratory failure. The horizontal line represents the mean risk-standardized mortality rate including sepsis/respiratory failure. Including patients with sepsis/respiratory failure causes a hospital's outlier status to improve, worsen, or remain the same.

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Figure 5.

Number of hospitals whose performance improved, remained the same, or declined when sepsis/respiratory failure cases were included in the definition of pneumonia.

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