Consensus Development and Application of ICD-9-CM Codes for Defining Chronic Illnesses and their Complications

Background: One particularly difficult challenge in evaluating disease management (DM) programs is defining the scope of economic outcomes to include in the evaluation. Measuring `all-cause utilization' or `total costs' assumes that a DM intervention impacts the entire spectrum of services rendered and reduces total medical costs, while limiting the evaluation to `disease-specific' costs of the conditions under management may fail to capture any effect the program may have on complications directly related to that primary condition. An acceptable compromise between the two options is to include costs associated with diagnostic codes for the primary condition and those of medical complications directly related to that condition. Objective: To develop consensus on the International Classification of Diseases, ninth revision, Clinical Modification (ICD-9-CM) codes defining the primary conditions and complications of coronary artery disease (CAD), congestive heart failure (CHF), asthma, and chronic obstructive pulmonary disease. Methods: A modified Delphi technique, involving two panels of three physicians each (one consisting of cardiologists and the other of pulmonologists) and a physician consultant, was conducted via email and used to establish 100% consensus on the ICD-9-CM codes to be included in order to capture the appropriate costs for each of the primary conditions considered and their complications. The codes for primary conditions included by the panel were compared with those included in industry references. Results: Total consensus on the codes to be included for each of the primary conditions was reached within three rounds. Near-consensus on the codes to be used for complications for conditions was reached after the first round; however, four additional rounds were required for total consensus. Regarding the primary conditions, greatest agreement between the codes included by the panel and the various industry references was seen for asthma, with poor agreement observed between sources of codes for CAD and CHF. Conclusion: It is suggested that these lists of ICD-9-CM codes developed by consensus be used in evaluations across the industry to define the utilization and/or costs associated with DM interventions. The consistent use of these codes will greatly strengthen the validity of the current evaluation approach and consequently substantiate the value proposition offered by the industry.Asthma, Chronic-obstructive-pulmonary-disease, Congestive-heart-failure, Coronary-artery-disease, Cost-analysis

Atrial Fibrillation (AFIB) in the ICU:Incidence, Risk Factors, and Outcomes: The International AFIB-ICU Cohort Study

OBJECTIVES: To assess the incidence, risk factors, and outcomes of atrial fibrillation (AF) in the ICU and to describe current practice in the management of AF. DESIGN: Multicenter, prospective, inception cohort study. SETTING: Forty-four ICUs in 12 countries in four geographical regions. SUBJECTS: Adult, acutely admitted ICU patients without a history of persistent/permanent AF or recent cardiac surgery were enrolled; inception periods were from October 2020 to June 2021. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We included 1,423 ICU patients and analyzed 1,415 (99.4%), among whom 221 patients had 539 episodes of AF. Most (59%) episodes were diagnosed with continuous electrocardiogram monitoring. The incidence of AF was 15.6% (95% CI, 13.8-17.6), of which newly developed AF was 13.3% (11.5-15.1). A history of arterial hypertension, paroxysmal AF, sepsis, or high disease severity at ICU admission was associated with AF. Used interventions to manage AF were fluid bolus 19% (95% CI 16-23), magnesium 16% (13-20), potassium 15% (12-19), amiodarone 51% (47-55), beta-1 selective blockers 34% (30-38), calcium channel blockers 4% (2-6), digoxin 16% (12-19), and direct current cardioversion in 4% (2-6). Patients with AF had more ischemic, thromboembolic (13.6% vs 7.9%), and severe bleeding events (5.9% vs 2.1%), and higher mortality (41.2% vs 25.2%) than those without AF. The adjusted cause-specific hazard ratio for 90-day mortality by AF was 1.38 (95% CI, 0.95-1.99). CONCLUSIONS: In ICU patients, AF occurred in one of six and was associated with different conditions. AF was associated with worse outcomes while not statistically significantly associated with 90-day mortality in the adjusted analyses. We observed variations in the diagnostic and management strategies for AF.</p