title: Multicenter study of surveillance for hospital-onset Clostridium difficile infection by the use of ICD-9-CM diagnosis codes.
abstract: OBJECTIVE
  To compare incidence of hospital-onset Clostridium difficile infection (CDI) measured by the use of International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) discharge diagnosis codes with rates measured by the use of electronically available C. difficile toxin assay results.
  
  
  METHODS
  Cases of hospital-onset CDI were identified at 5 US hospitals during the period from July 2000 through June 2006 with the use of 2 surveillance definitions: positive toxin assay results (gold standard) and secondary ICD-9-CM discharge diagnosis codes for CDI. The chi(2) test was used to compare incidence, linear regression models were used to analyze trends, and the test of equality was used to compare slopes.
  
  
  RESULTS
  Of 8,670 cases of hospital-onset CDI, 38% were identified by the use of both toxin assay results and the ICD-9-CM code, 16% by the use of toxin assay results alone, and 45% by the use of the ICD-9-CM code alone. Nearly half (47%) of cases of CDI identified by the use of a secondary diagnosis code alone were community-onset CDI according to the results of the toxin assay. The rate of hospital-onset CDI found by use of ICD-9-CM codes was significantly higher than the rate found by use of toxin assay results overall (P < .001), as well as individually at 3 of the 5 hospitals (P < .001 for all). The agreement between toxin assay results and the presence of a secondary ICD-9-CM diagnosis code for CDI was moderate, with an overall kappa value of 0.509 and hospital-specific kappa values of 0.489-0.570. Overall, the annual increase in CDI incidence was significantly greater for rates determined by the use of ICD-9-CM codes than for rates determined by the use of toxin assay results (P = .006).
  
  
  CONCLUSIONS
  Although the ICD-9-CM code for CDI seems to be adequate for measuring the overall CDI burden, use of the ICD-9-CM discharge diagnosis code for CDI, without present-on-admission code assignment, is not an acceptable surrogate for surveillance for hospital-onset CDI.
authors.affiliation: Washington University School of Medicine, St Louis, Missouri, USA. edubberk@im.wustl.edu
authors.forename: Erik R
authors.initials: ER
authors.lastname: Dubberke
authors.forename: Anne M
authors.initials: AM
authors.lastname: Butler
authors.forename: Deborah S
authors.initials: DS
authors.lastname: Yokoe
authors.forename: Jeanmarie
authors.initials: J
authors.lastname: Mayer
authors.forename: Bala
authors.initials: B
authors.lastname: Hota
authors.forename: Julie E
authors.initials: JE
authors.lastname: Mangino
authors.forename: Yosef M
authors.initials: YM
authors.lastname: Khan
authors.forename: Kyle J
authors.initials: KJ
authors.lastname: Popovich
authors.forename: Kurt B
authors.initials: KB
authors.lastname: Stevenson
authors.forename: L Clifford
authors.initials: LC
authors.lastname: McDonald
authors.forename: Margaret A
authors.initials: MA
authors.lastname: Olsen
authors.forename: Victoria J
authors.initials: VJ
authors.lastname: Fraser
mesh_terms: D000328:Adult; D001681:Biological Assay; D016360:Clostridioides difficile / Q000302:isolation & purification*; D003428:Cross Infection / Q000175:diagnosis / Q000453:epidemiology* / Q000209:etiology; D006801:Humans; D038801:International Classification of Diseases; D016014:Linear Models; D010351:Patient Discharge; D011159:Population Surveillance / Q000379:methods; D014481:United States / Q000453:epidemiology