Administrative data are used extensively for research purposes, but there remains limited information on the quality of these data for identifying comorbidities related to stroke. To compare the prevalence of comorbidities of stroke identified using International Classification Diseases, Australian Modification (ICD-10-AM) or Anatomical Therapeutic Chemical codes, with those from (i) self-reported data and (ii) published studies. The cohort included patients with stroke or transient ischaemic attack admitted to hospitals (2012-2016; Victoria and Queensland) in the Australian Stroke Clinical Registry (N = 26,111). Data were linked with hospital and pharmaceutical datasets to ascertain comorbidities using published algorithms. The sensitivity, specificity, and positive predictive value of these comorbidities were compared with survey responses from 623 patients (reference standard). An indirect comparison was also performed with clinical data from published stroke studies. The sensitivity of hospital ICD-10-AM data was poor for most comorbidities, except for diabetes (93.0%). Specificity was excellent for all comorbidities (87-96%), except for hypertension (70.5%). Compared to published stroke studies (3 clinical trials and 1 incidence study), the prevalence of diabetes and atrial fibrillation in our cohort was similar using ICD-10-AM codes, but lower for dyslipidaemia and anxiety/depression. Whereas in the pharmaceutical dispensing data, the sensitivity was excellent for dyslipidaemia (94%) and modest for anxiety/depression (77%). In the pharmaceutical data, specificity was modest for hypertension (78%) and anxiety or depression (76%), but specificity was poor for dyslipidaemia (19%) and heart disease (46%). Variation was observed in the reporting of comorbidities of stroke in administrative data, and consideration of multiple sources of data may be necessary for research. Further work is needed to improve coding and clinical documentation for reporting of comorbidities in administrative data.

The percentage of total body surface area (%TBSA) burned and burn depth provide valuable information on burn injury severity. This study investigated the concordance between The International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Australian Modification (ICD-10-AM) codes and expert burn clinicians in assessing burn injury severity. We conducted a retrospective population-based review of all patients who sustained a burn injury between July 1, 2009, and June 30, 2019, requiring admission into a specialist burn service across Australia and New Zealand. The %TBSA burned (including the percentage of full thickness burns) recorded by expert burn clinicians within the Burns Registry of Australia and New Zealand (BRANZ) were compared to ICD-10-AM coding. 20,642 cases (71.5%) with ICD-10-AM code data were recorded. Overall, kappa scores (95% confidence interval [CI]) for burn size ranged from 0.64 (95% CI 0.63-0.66) to 0.86 (95% CI 0.78-0.94) indicating substantial to almost perfect agreement across all %TBSA groups. When stratified by depth, the lowest agreement was observed for < 10% TBSA and < 10% full thickness (kappa 0.03; 95% CI 0.02-0.04) and the highest agreement was observed for burns of ≥ 90% TBSA and ≥ 90% full thickness (kappa 0.72; 95% CI 0.58-0.85). Overall, there was substantial agreement between the BRANZ and ICD-10-AM coded data for %TBSA classification. When %TBSA classification was stratified by burn depth, greater agreement was observed for larger and deeper burns compared with smaller and superficial burns. Greater consistency in the classification of burns is needed.

The management of data on coronary artery disease (CAD) plays a significant role in controlling the disease and reducing the mortality of patients. The diseases registries facilitate the management of data. This study aimed to identify the attributes of hospital-based CAD registries with a focus on key registry processes. In this systematic review, we searched for studies published between 2000 and 2019 in PubMed, Scopus, EMBASE and ISI Web of Knowledge. The search terms included coronary artery disease, registry and data management (MeSH terms) at November 2019. Data gathering was conducted using a data extraction form, and the content of selected studies was analysed with respect to key registry processes, including case finding, data gathering, data abstracting, data quality control, reporting and patient follow-up. A total of 17,604 studies were identified in the search, 55 of which were relevant studies that addressed the 21 registries and were selected for the analysis. Results showed that the most common resources for case finding included admission and discharge documents, physician's reports and screening results. Patient follow-up was mainly performed through direct visits or via telephone calls. The key attributes used for checking the data quality included data accuracy, completeness and definition. CAD registries aim to facilitate the assessment of health services provided to patients. Putting the key registry processes in place is crucial for developing and implementing the CAD registry. The data quality control, as a CAD registry process, requires developing standard tools and applying appropriate data quality attributes. The findings of the current study could lay the foundation for successful design and development of CAD registries based on the key registry processes for effective data management.

Clinical documentation improvement (CDI) is a recent initiative gaining increased momentum in Australia. The benefits surrounding its success internationally include improved quality and patient safety outcomes and increased reimbursement. The premise of CDI is simple: engage clinicians to improve the clinical documentation in the medical record in "real time" so that it is fit for reporting, analysis and reimbursement. Every country has differing healthcare systems and this article has focused on validating the relevancy of CDI for the Australian healthcare environment.

The accuracy of data on suicide-related presentations to Emergency Departments (EDs) has implications for the provision of care and policy development, yet research on its validity is scarce. To test the reliability of allocation of ICD-10 codes assigned to suicide and self-related presentations to EDs in Queensland, Australia. All presentations due to suicide attempts, non-suicidal self-injury (NSSI) and suicidal ideation between 1 July 2017 and 31 December 2017 were reviewed. The number of presentations identified through relevant ICD-10-AM codes and presenting complaints in the Emergency Department Information System were compared to those identified through an application of an evolutionary algorithm and medical record review (gold standard). A total of 2540 relevant presentations were identified through the gold standard methodology. Great heterogeneity of ICD-10-AM codes and presenting complaints was observed for suicide attempts (40 diagnostic codes and 27 presenting complaints), NSSI (27 and 16, respectively) and suicidal ideation (38 and 34, respectively). Relevant ICD codes applied as primary or secondary diagnosis had very low sensitivity in detecting cases of suicide attempts (18.7%), NSSI (38.5%) and suicidal ideation (42.3%). A combination of ICD-10-AM code and a relevant presenting complaint increased specificity, however substantially reduced specificity and positive predictive values for all types of presentations. ED data showed bias in detecting higher percentages of suicide attempts by Indigenous persons (10.1% vs. 6.9%) or by cutting (28.1% vs. 10.3%), and NSSI by female presenters (76.4% vs. 67.4%). Suicidal and self-harm presentations are grossly under-enumerated in ED datasets and should be used with caution until a more standardised approach to their formulation and recording is implemented.

Malnutrition is a disease that imposes a significant healthcare cost burden in the United States, especially when left undiagnosed and untreated for an extended period of time. This article discusses traditional malnutrition diagnostic criteria for adults and why registered dietitian nutritionists and physicians should no longer use these criteria to determine nutrition status. It concludes with the malnutrition clinical characteristics currently accepted in the United States and globally, with implications for practice. Clinical documentation specialists and medical coders can use this information to better interpret medical record documentation and assign the correct International Classification of Diseases, 10th Revision, Clinical Modification codes to the coding abstract.

Although in recent times the Saudi government has paid much attention to the adaptation of hospital information systems (HIS) and electronic medical records (EMR), the importance of utilising HIS to enhance medical research has been neglected. We aimed to (i) investigate the current state of medical research in Saudi Arabia, (ii) identify possible issues that hinder improvement of medical research and (iii) identify possible solutions to enhance the role of HIS in medical research in Saudi Arabia. We used a questionnaire and structured interview approach. Questionnaires were distributed to Saudi healthcare professionals. One hundred responses to our questionnaire were captured by the online Google Form designed specifically for our survey. Structured interviews with two IT professionals were conducted regarding technical aspects of their hospital data management systems. Six themes contributing to the inefficacy of HIS in medical research in Saudi Arabia emerged from the data: incorrect datasets, difficult data collection and storage, poor data analytics, a lack of system interoperability across different HIS for universal access and negative perception of the usefulness of HIS for medical research. Our findings suggest (i) cloud-based HIS would support efficient, reliable and integrated data collection and storage across all hospitals in Saudi Arabia; (ii) EMR data sources should be seamlessly linked to avoid incomplete, fragmented or erroneous EMR in Saudi Arabia; and (iii) collaboration between all hospitals in Saudi Arabia to adopt a uniform standard to support interoperability and improve data exchange and integration is necessary.

Medication administration omission errors (MAOEs) occur frequently in hospitals and can significantly affect patient health. An interdisciplinary committee was formed in summer 2012 to analyse incident/accident reports (AH-223-1 forms) of MAOEs for the 2011-2012 fiscal year in order to identify contributing factors and to propose preventive solutions. Special attention was paid to events with consequences for patients. An aggregate data analysis involving four major steps was conducted: sampling, categorisation, identification of contributing factors, and seeking preventive solutions. One hundred omissions were randomly selected from the 889 reported for this period. All omissions categorised as having had consequences for patients were then added, making a final total of 145 omissions. The omissions were categorised using an Ishikawa diagram developed from an exploratory literature review and process mapping. Subsequent to failure modes, effects and criticality analysis, cause-and-effect diagrams were constructed with the main prioritised categories to differentiate the proximal causes from the root causes. Brainstorming was used to develop solutions, which were then prioritised with an impact/effort matrix. This study identified 27 categories of MAOEs, of which the 7 most frequent and the most critical accounted for 79.3% of the reports. The event categories, in decreasing order of importance, were related to intravenous (IV) therapy (29.0%), failure in using the medication administration record (MAR; 23.4%), failure in creating/updating the MAR (10.3%), medications on the patient's bedside (7.6%), and three types of MAOEs related to transcribing prescriptions (9.0%). The interdisciplinary committee formulated 10 main recommendations related to these 7 categories, including 3 for IV therapy and 4 for failure in using or creating/updating the MAR.