Spine Pain in VA: Right Cohorto Patsi Sinnott. Andrea Shane, Andrew Siroka Todd Wagner, Jodie Trafton July 21, 2010
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1 Spine Pain in VA: Finding the Complete/ Right Cohorto Patsi Sinnott Andrea Shane, Andrew Siroka Todd Wagner, Jodie Trafton July 21, 2010
2 Outline Background Methods Results Discussioni 2
3 Background Musculoskeletal kltlsi Spine Pi Pain in VA, Description and Guideline Adherence (IIR ) Observational study: Administrative data Spine vs. neck vs. back Acute, mechanical or non-specific spine pain 3
4 Background Back kpi Pain Pti Patient tot Outcomes Assessment tteam (BOAT) (PI Deyo) the back pain PORT, supported by AHCPR, analyzes practice variations and examines the relative effectiveness of alternative ways of diagnosing and treating back pain 70 publications Evaluate diagnostic tests, surgery and various interventions 4
5 Background Mechanical or non-specific low back or neck pain ICD and CPT codes to identify patients in admin data Incidence, prevalence - proxy for morbidity Inclusion and exclusion algorithms Surgical and non-surgical inpatient stays Variation in surgical rates 5
6 Key publications Background Volinn E, Mayer J, Diehr P, Van Koevering D, Connell llfa, Loeser JD. Small area analysis of surgery for low-back pain. Spine (Phila Pa 1976). May 1992;17(5): Cherkin DC, Deyo RA, Volinn E, Loeser JD. Use of the International Classification of Diseases (ICD-9-CM) to identify hospitalizations for mechanical low back problems in administrative databases. Spine. 1992;17(7):
7 Background Einstadter D, Kent DL, Fihn SD, Deyo RA. Variation in the rate of cervical spine surgery in Washington State. Med Care. Aug 1993;31(8):
8 Background AHRQ Healthcare Cost and Utilization Project (HCUP) Clinical Classification Software (CCS) 1988 Homogenous clusters of interest to public policy researchers Diagnostic and procedural categories Technical specialists Continuing review for accuracy and clinical significance ifi 8
9 Pi Primary assumptions: Objectives Changes in medical practice Change in research capacity Changes in research focus Review algorithms used to identify patients with spine pain in administrative data Revise algorithm if warranted 9
10 Objective Establish a standard d methodology to identify patients with spine pain in administrative data 10
11 Mthd Methods Review ICD and coding methodology Identify literature that reports using ICD or CPT codes to identify patients with spine pain and spine surgery in administrative data Consolidate definitions if possible Synthesize and test code lists for completeness 11
12 Results Cdi Coding methodology hdl CPT Procedures and surgeries five digit ICD Diagnoses and procedures Three digit Four digit Five i digit i 12
13 Coding methodology 721- Spondylosis and allied disorders d Thoracic or lumbar spondylosis with myelopathy Thoracic spondylosis with myelopathy Lumbar spondylosis with myelopathy 13
14 Pubmed BOAT report Literature t Review Web of knowledge HCUP CCS categories 14
15 Lit review - PubMed In any field: Back and dicd and prevalence; Neck and ICD and prevalence; Back and ICD and surgery; Neck and ICD and surgery; Back and CPT and prevalence; Neck and CPT and prevalence; Back and CPT and surgery; and Neck and CPT and surgery. In the Title: Back pain and prevalence; Neck pain and prevalence; Back pain and surgery; and Neck pain and surgery. 15
16 Lit Review ew BOAT Web of Knowledge Web of Knowledge (Thomson Reuters Institute for Scientific Information sm ) 16
17 Results 40 papers Excluded those that: Did not include a specific list of inclusion or exclusion codes Did not use administrative data Six papers in final synthesis 17
18 Final Review Six papers and two HCUP CCS categories Volinn E, Mayer J, Diehr P, Van Koevering D, Connell FA, Loeser JD. Small area analysis of surgery for low-back pain. Spine (Phila Pa 1976). May 1992;17(5): Cherkin DC, Deyo RA, Volinn E, Loeser JD. Use of the International Classification of Diseases (ICD-9-CM) to identify hospitalizations for mechanical low back problems in administrative databases. Spine. 1992;17(7): Einstadter D, Kent DL, Fihn SD, Deyo RA. Variation in the rate of cervical spine surgery in Washington State. t MdC Med Care. Aug 1993;31(8): (8) 718 Taylor VM, Anderson GM, McNeney B, et al. Hospitalizations for back and neck problems: a comparison between the Province of Ontario and Washington State. Health Serv Res. Oct 1998;33(4 Pt 1): Angevine PD, Arons RR, McCormick PC. National and regional rates and variation of cervical discectomy with and without anterior fusion, Spine (Phila Pa 1976). May ;28(9): ; discussion 940. Martin BI, Deyo RA, Mirza SK, et al. Expenditures and health status among adults with back and neck problems. JAMA. Feb ;299(6):
19 Coding algorithms.table A 19
20 HCUP CCS Back 205 Spondylosis, intervertebral t disc disorders; other back problems
21 HCUP-CCSCCS Sprains and Strains
22 Dfiiti Definitions Mechanical or non-specific spine pain Associated with pain including radicular symptoms Excluding Neoplasm, infectious, inflammatory causes Associated with pregnancy or trauma 22
23 White Board 23
24 Dfiiti Definitions Cherkin DC, Deyo RA, Volinn E, Loeser JD. Use of the International Classification of Diseases (ICD-9-CM) to identify hospitalizations for mechanical low back problems in administrative databases. Spine. 1992;17(7): (7) 825 Elixhauser A, Andrews RM, Fox S. Clinical classifications for health policy research: Discharge statistics by principal diagnosis and procedure. Rockville, MD: Agency for Health Care Policy and Research; Dionne CE, Dunn KM, Croft PR, et al. A consensus approach toward the standardization of back pain definitions for use in prevalence studies. Spine (Phila Pa 1976). Jan ;33(1):
25 HCUP CCS Cherkin & Deyo Dfiiti Definitions Martin Neck and Back Dionne 25
26 Dfiiti Definitions Conditions that t originate i anywhere in the spine Neck pain cervical spine Back pain thoracic, lumbar, sacral and coccygeal spine Low back pain lumbar, sacral, coccygeal spine 26
27 Definitions 27
28 Cervical spine Thoracic spine Thoraco-lumbar spine Lumbar spine Lumbo-sacral spine Sacral spine Coccyx Dfiiti Definitions 28
29 Consolidated d list View Excel table :Combined back and neck Summary of all codes Indicates inclusion and exclusion per each paper or HCUP category 29
30 Patterns Inclusion/exclusion l i based on criteria i described in paper or software Neck pain does not include TLSC spine and vice versa HCUP definition back=all spine Martin = broadest definition of back and neck: Angevine = most narrow 30
31 Testing: Global l Exclusions View Table 9 Exclusions 31
32 Sequential additions - Back View Table 7 32
33 Sequential additions - Neck View Table 8 33
34 Surgery and Procedures View excel worksheet Surgery and Procedures 34
35 View Table 10. Non-specific codes 35
36 Algorithms to specify surgery View Table 11 36
37 Dfii Defining your cohort Mechanical or non-specific spine pain Excluding Neoplasm, infectious, inflammatory causes Associated with pregnancy Associated with trauma (?) Surgical and/or non-surgical patients? 37
38 Dfii Defining your cohort Which h spinal segment(s)? Back Low back Neck Thoracic spine, sacrum and coccyx 38
39 Dfii Defining your cohort BOAT algorithm (?) What to do about: Ankylosing spondylitis, etc ( ) Curvatures of the spine ( , excludes congenital) Acquired spondylolisthesis li i and other acquired deformity of the back or spine ( ) 39
40 Dfii Defining your cohort What to do about: Nonallopathic lesions of the spine ( ) Anomalies of the spine ( ) Open/closed spinal fractures ( ) Other..vertebral ertebral dislocations ( ) 40
41 Dfii Defining your cohort Cd Codes where spinal segment not specified ifid (e.g. could be back or neck) 41
42 How we are proceeding Acute, mechanical or non-specific spine pain Including all spine segments and diagnoses Identify all Veterans treated for spine pain in FY Identify first event in data 42
43 How we are proceeding Excluding global lconditions i (if appear twice in a year, etc) Excluding post-surgical cases (no spinal procedures within 1 year of entering the spine pain cohort) Excluding trauma and fractures E-codes and vertebral fractures open and closed (major codes ) 43
44 How we are proceeding Dfi Define spinal segment by ICD code when possible Require additional diagnoses to confirm spinal segment for those cases with non- specific coding. Summarize and report 44
45 Questions? 45
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