Carlson KF (Minneapolis VAMC), Sayer NA
(Minneapolis VAMC), Chiros C
(Minneapolis VAMC), Nugent S
(Minneapolis VAMC), Grill J
Veterans from Operations Iraqi Freedom/Enduring Freedom (OIF/OEF) are using VA services for injuries incurred during and after their military service. The objectives of this study were to: a) determine whether ICD-9 supplemental external cause-of-injury codes (e-codes) can be used to identify causes of injury among OIF/OEF VA users, and b) identify sources of variation in coding practice across VA Polytrauma Rehabilitation Centers (PRCs).
We reviewed CPRS chart notes for 566 consecutive patients treated at one of 4 PRCs between 2001 and 2006 and who served after the Persian Gulf War. A certified medical records coder and an experienced injury epidemiologist assigned “gold standard” e-codes to each patient based on the same CPRS chart notes used by VA coders. Gold standard coders were blinded to e-codes already assigned by VA coders. VA diagnosis and e-codes were extracted from VISTA. Analyses included descriptive summaries based on gold standard e-codes and measures of agreement between gold standard and VA e-codes by major source-of-injury categories.
Most (95%) PRC patients were male. Ages were 18-59 years (mean=26; SD=7). The majority (n=514; 91%) received rehabilitation for externally-caused injuries. Injuries for 181 patients (35%) were incurred during OIF/OEF deployment. Based on gold standard e-codes, the most frequent sources of injury included motor vehicles (n=280; 55%), blasts/bullets (n=132; 26%), falls (n=38; 7%), and intentional harm (5%), including suicide attempts (n=4) and assaults (n=24). Only 381 (74%) records were assigned e-codes by VA coders. Therefore, kappa values for agreement between gold standard and VA e-codes were poor. Sources of variability in agreement were facility, combat-relatedness, and source-of-injury. For example, kappa values ranged from .62 for motor vehicles, to .77 for blasts/bullets.
VA coders are not assigning e-codes to all patients receiving inpatient rehabilitation for externally-caused injuries. E-codes are not a reliable source of information on cause of injury.
VA needs valid, cost-efficient strategies for identifying causes of patient injuries. Although e-codes were developed for this purpose, current VA e-coding practices are not reliable. Identified sources of variation in VA e-coding practices can be used to inform quality improvement efforts.