Identification of volume overload hospitalizations among hemodialysis patients using administrative claims: a validation study.
High rates of volume overload hospitalizations may indicate inadequate dialysis facility fluid management. Administrative claims databases are often used to study such outcomes, but these data are generated for billing purposes and may not capture clinical nuance. It is unknown if volume overload admissions can be correctly identified in administrative data and if a single claims-based definition for volume overload can be used across epidemiologic surveillance studies, observational studies of exposure-outcome associations and quality assessments. We conducted a validation study to assess the accuracy of claims-based definitions for volume overload hospitalizations among hemodialysis patients.



Data were taken from a random sample of 315 adult hemodialysis patients admitted to University of North Carolina Hospitals from January 2010 through June 2013. Standardized chart reviews were conducted to clinically adjudicate the presence or absence of volume overload at hospital admission. Claims-based definitions were constructed from varying combinations of fluid-related ICD-9 discharge diagnosis codes including fluid overload, pulmonary edema, pleural effusion, and heart failure. Using clinically adjudicated volume overload hospitalizations as the reference standard, validity metrics and their 95 % confidence intervals (CIs) were estimated for each definition.



Of the 315 hospital admissions, 77 (24.4 %) were clinically adjudicated as volume overload hospitalizations. The prevalence of claims-identified volume overload admissions varied across definitions, ranging from 1.6 to 37.1 %. When definitions were constructed with discharge diagnosis codes present in any billing position, volume overload hospitalizations defined by fluid overload, pleural effusion or heart failure diagnosis codes had the highest sensitivity, 81.8 % (95 % CI: 71.4 %, 89.7 %). Volume overload hospitalizations defined by pulmonary edema diagnosis codes had the highest specificity, 98.3 % (95 % CI: 95.8 %, 99.5 %). Definitions constructed with discharge diagnosis codes present in any billing position (versus the primary position) captured more false positive events.



Prevalence and validity estimates of volume overload hospitalizations vary across claims-based definitions. A universal claims-based definition for volume overload hospitalizations may not apply to all clinical and research scenarios. Investigators and regulators need to consider the implications of misclassifying events when evaluating and monitoring hemodialysis patient volume overload admissions with administrative data. Claims-based definitions should be selected accordingly.
Division of Nephrology and Hypertension, Department of Medicine, University of North Carolina Kidney Center, UNC School of Medicine, 7024 Burnett-Womack CB #7155, Chapel Hill, NC, 27599-7155, USA.|Department of Epidemiology, UNC Gillings School of Global Public Health, Chapel Hill, NC, USA.
Magdalene M
MM
Assimon
Department of Medicine, UNC School of Medicine, Chapel Hill, NC, USA.
Thuy
T
Nguyen
Division of Nephrology and Hypertension, Department of Medicine, University of North Carolina Kidney Center, UNC School of Medicine, 7024 Burnett-Womack CB #7155, Chapel Hill, NC, 27599-7155, USA.
Suzanne L
SL
Katsanos
DaVita Clinical Research, Minneapolis, MN, USA.
Steven M
SM
Brunelli
Division of Nephrology and Hypertension, Department of Medicine, University of North Carolina Kidney Center, UNC School of Medicine, 7024 Burnett-Womack CB #7155, Chapel Hill, NC, 27599-7155, USA. jflythe@med.unc.edu.|Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, NC, USA. jflythe@med.unc.edu.
Jennifer E
JE
Flythe
D000067575:Administrative Claims, Healthcare; D000328:Adult; D000368:Aged; D002318:Cardiovascular Diseases / Q000175:diagnosis* / Q000209:etiology; D045604:Extracellular Fluid; D005260:Female; D006333:Heart Failure / Q000175:diagnosis / Q000209:etiology; D006760:Hospitalization / Q000706:statistics & numerical data*; D006801:Humans; D038801:International Classification of Diseases; D008297:Male; D008875:Middle Aged; D010996:Pleural Effusion / Q000175:diagnosis / Q000209:etiology; D011654:Pulmonary Edema / Q000175:diagnosis / Q000209:etiology; D011787:Quality of Health Care; D006435:Renal Dialysis / Q000009:adverse effects* / Q000592:standards; D012680:Sensitivity and Specificity
Administrative claims; Hemodialysis; Hospitalization; ICD-9; Volume overload