Background In 2016, the CDC in the USA proposed codes from the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) for identifying traumatic brain injury (TBI). This study estimated positive predictive value (PPV) of TBI for some of these codes. Methods Four study sites used emergency department or trauma records from 2015 to 2018 to identify two random samples within each site selected by ICD-10-CM TBI codes for (1) intracranial injury (S06) or (2) skull fracture only (S02.0, S02.1-, S02.8-, S02.91) with no other TBI codes. Using common protocols, reviewers abstracted TBI signs and symptoms and head imaging results that were then used to assign certainty of TBI (none, low, medium, high) to each sampled record. PPVs were estimated as a percentage of records with medium-certainty or high-certainty for TBI and reported with 95% confidence interval (CI). Results PPVs for intracranial injury codes ranged from 82% to 92% across the four samples. PPVs for skull fracture codes were 57% and 61% in the two university/trauma hospitals in each of two states with clinical reviewers, and 82% and 85% in the two states with professional coders reviewing statewide or nearly statewide samples. Margins of error for the 95% CI for all PPVs were under 5%. Discussion ICD-10-CM codes for traumatic intracranial injury demonstrated high PPVs for capturing true TBI in different healthcare settings. The algorithm for TBI certainty may need refinement, because it yielded moderate-to-high PPVs for records with skull fracture codes that lacked intracranial injury codes.

中文翻译：

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外伤性脑损伤急诊就诊的多站点病历审查

背景 2016 年，美国 CDC 提出了国际疾病分类第十次修订、临床修改 (ICD-10-CM) 中用于识别外伤性脑损伤 (TBI) 的代码。本研究估计了其中一些代码的 TBI 阳性预测值 (PPV)。方法 四个研究中心使用 2015 年至 2018 年的急诊科或外伤记录，在通过 ICD-10-CM TBI 代码选择的每个中心内确定两个随机样本，用于（1）颅内损伤（S06）或（2）仅颅骨骨折（S02）。 0、S02.1-、S02.8-、S02.91)，没有其他 TBI 代码。使用通用协议，审阅者提取 TBI 体征和症状以及头部成像结果，然后将这些结果用于为每个采样记录分配 TBI 的确定性（无、低、中、高）。PPV 被估计为具有中等确定性或高确定性 TBI 记录的百分比，并以 95% 置信区间 (CI) 报告。结果四个样本中颅内损伤代码的 PPV 范围从 82% 到 92%。两个州的两家大学/创伤医院的颅骨骨折代码 PPV 分别为 57% 和 61%，有临床审查员，两个州的 PPV 分别为 82% 和 85%，有专业编码员审查全州或几乎全州的样本。所有 PPV 的 95% CI 的误差幅度均低于 5%。讨论 ICD-10-CM 外伤性颅内损伤代码证明了在不同医疗环境中捕获真实 TBI 的高 PPV。TBI 确定性的算法可能需要改进，因为它为具有颅骨骨折代码但缺乏颅内损伤代码的记录产生了中到高的 PPV。