Abstract Wall

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Abstract Wall

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HOW TO PAINT ABSTRACT WALL ART Art lessons

Case definitions for acute myocardial infarction in administrative databases and their impact on in-hospital mortality rates.

Acute myocardial infarction (AMI) is an important health issue that
has been widely studied in the literature both in terms of its clinical
impact on the population and its inclusion as part of performance
indicators (Yeh and Go 2010). However, the essential question of what
constitutes an AMI clinically remains unaddressed, resulting in
heterogeneity between study findings (Thygesen et al. 2007; Yeh and Go
2010). The lack of a common clinical definition further complicates
population-based studies that rely on administrative data that are coded
from this heterogeneous pool of clinical definitions.

Administrative data such as hospital discharge abstract data,
physician billing data, health insurance plan registries, and vital
statistics repositories are employed for many different purposes in part
due to their wide population-coverage, their cost-effectiveness, and the
fact that they are often a readily available source of data.
Administrative health databases typically code medical conditions using
the World Health Organization International Classification of Diseases
and Related Disorders (ICD) codes, and as such are very useful tool for
research. Today, most countries use ICD-9 (first released in 1975),
ICD-9-CM (Clinical Modification), or ICD- 10 (first released in 1990) to
classify their national morbidity and mortality data, making these
coding systems the most widely used classification systems underlying
health care data internationally (Jette et al. 2010; World Health
Organization 2010).

Although administrative data are used to estimate the incidence and
prevalence of acute conditions requiring hospital admission,
administrative data were not originally intended to be collected for
disease surveillance (Tu et al. 1999; Austin, Daly, and Tu 2002). As a
result, it is important to assess disease coding validity from
administrative databases for conditions such as AMI before proceeding
with any outcome analysis or epidemiological studies. A case definition
for a disease can simply consist of the appearance of a single disease
code at any point in time in any administrative data source (i.e., if a
patient has one physician visit for the condition of interest, he or she
is classified as having the disease), or it can use an algorithm to
identify patients with the disease (i.e., a patient is only classified
as having the disease if he or she had two physician visits and one
emergency room visit coded with the condition of interest within a
2-year period) (Quan et al. 2009). Numerous studies have been published
using administrative hospitalization data to study various AMI outcomes;
however, the case definitions used have often not been validated prior
to their implementation and are inconsistent across studies, which may
lead to incomparable findings.

The objectives of this study were to (1) perform a systematic
review of hospital-based studies to identify validated ICD-9-,
ICD-9-CM-, or ICD-10based AMI case definitions; (2) identify what case
definitions have been used in the literature; (3) validate previously
validated case definitions in dually coded ICD-9-CM and ICD-10 data
through medical chart review; and (4) apply validated AMI case
definitions to Canadian hospital discharge abstract data to assess the
impact of various case definitions on estimates of AMI admissions and
in-hospital mortality.

METHODS

Literature Review of Validated AMI Case Definitions

A systematic literature search was conducted in July 2010 using
Ovid Medline (1950 to present) for the following terms: myocardial
infarction or cardiac infarct or heart infarct or myocardial infarct or
acute myocardial infarction; AND case definition or admin data or
administrative data or algorithms or computer algorithms or registries
or International Classification of Diseases or ICD-9 or ICD-9CM or
ICD-10 or ICD code or patient coding or patient classification or
disease classification or disease coding or international classification
disease. The search was limited to English language articles only. All
abstracts were reviewed independently by two authors, and full-text
articles were reviewed if one of the two reviewers thought the article
may be relevant at the abstract review stage. Full-text articles were
included if both reviewers agreed that the article met all eligibility
criteria: validated AMI ICD-9 or ICD-10 codes (including any
country-specific modification in these coding frameworks); specified the
ICD codes used in hospital discharge abstract data; and reported
sensitivity, specificity, positive predictive value (PPV), or negative
predictive value (NPV) or provided the data required to calculate these
values. Reference lists were also hand searched to ensure no additional
studies were missed. Disagreements between reviewers were resolved by
consensus.

Data on sensitivity, specificity, PPV, and NPV (when available)
were abstracted by two reviewers from validated case definitions and
summarized in tabular form. In addition, data were also abstracted on
study characteristics (such as sample size, years of data collection,
validation database, and gold standard) and the specific ICD codes used
in the validation.

Literature Review of Case Definitions Used in AMI studies

Due to the high volume of publications on AMI, we searched
high-impact general medical journals (i.e., British Medical Journal,
Canadian Medical Association Journal, Journal of the American Medical
Association, Lancet, New England Journal of Medicine) and high-impact
cardiovascular journals (i.e., American Journal of Cardiology,
Circulation, Heart, Journal of the American College of Cardiology) and
determined what ICD-based case definitions for AMI were most commonly
used in the scientific literature. A literature search of these journals
using Ovid Medline (2007-2012) was conducted in February 2012 using the
following terms: myocardial infarction or acute myocardial infarction;
and medical records or health services or health services research or
insurance, hospitalization, or length of stay or risk adjustment or
hospitals or databases, factual. Journal articles were included if they
used an ICD-9- or ICD-10-based case definition for AMI and reported the
ICD codes used.

Validating AMI Case Definitions in Dually Coded ICD-9-CM and ICD-10
Hospital Discharge Data

We randomly selected 4,008 inpatients records from hospital
discharge abstract data who were admitted between January 1 and June 30,
2003, for any indication. Up to 25 diagnoses per encounter were coded
using ICD-10. Trained health coders recoded these inpatient charts using
ICD-9-CM using standard coding methodology. Charts were then
independently reviewed by trained reviewers with nursing backgrounds.
Reviewers were instructed to examine the entire chart, including the
cover page, admission notes, laboratory results, and discharge
summaries. A chart was coded as indicating the presence of AMI based on
all available documentation and if the AMI was not present on admission.
Thus, for 4,008 inpatients, three datasets were created: ICD-9-CM,
ICD-10, and chart review datasets. Details were reported elsewhere (Quan
et al. 2008). Sensitivity, specificity, PPV, and NPV were calculated for
ICD-9-CM and ICD-10 data (found in any coding position), respectively,
accepting the chart data as a reference standard for each AMI case
definition.

AMI Case Volume and In-Hospital Mortality in Hospital Discharge
Data

AMI case definitions were applied to the hospital discharge
abstract data from Calgary, Alberta, Canada, from April 2001 to March
2002 (ICD-9 coded data) and April 2006 to March 2007 (ICD- 10 coded
data). Hospitals in Calgary serve a population of 1.4 million
individuals. These data encompass all patients who were admitted to
hospital and include numerous variables such as length of stay,
diagnoses, interventions, and in-hospital mortality. Up to 50 diagnoses
per case are recorded in this database. AMI patients were defined using
the primary diagnosis alone and then using primary and secondary
diagnoses (i.e., conditions were coded in any coding field). Patients
were included in this analysis if they were 18 years of age or older at
the time of admission. For patients with multiple admissions, only the
first admission in the fiscal year was used in the analysis. For each
case definition, the number of patients identified and the in-hospital
mortality rate was assessed among those identified.

RESULTS

Literature Review of Validated AMI Case Definitions

Of 3,603 articles identified, 26 articles from nine countries,
including Australia, Canada, Finland, Korea, the Netherlands, New
Zealand, Scotland, Sweden, and United States, met all inclusion criteria
(Figure 1). Nine ICD-9 and two ICD-10 codes were used in these studies
in eight combinations (see Tables 1 and 2). All these studies included
ICD-9 code 410 (AMI) in either the primary (major reason for admission
or resource consumption) or one of the secondary diagnostic code
positions (co-existing condition) to identify patients with AMI. The
second most frequently used code was ICD-9 411 (other acute and subacute
forms of ischemic heart disease). Only one study validated ICD-10 codes,
I21 (acute myocardial infarction, disregarding any ICD-10 subgroups) and
I22 (subsequent myocardial infarction, disregarding any ICD-10
subgroups), and combined these codes with ICD-9 code 410 (Pajunen et al.
2005). Most studies did not differentiate whether a particular code of
interest was in the primary position or in one of the secondary
positions. Of the 26 studies reviewed, 17 used medical records and 9
used registry data as the gold standard to validate AMI diagnosis in
hospital discharge data. ICD-9 codes 410-414 had the highest reported
sensitivity (range: 79-95 percent), whereas ICD-9 code 410 used in
isolation had the highest reported specificity (range: 89-99 percent)
(see Table 2).

[FIGURE 1 OMITTED]

PPV was reported in 22 studies (range: 5.6-98.7 percent). The ICD-9
code 410 used in isolation had the highest reported PPV (range:
54.6-98.7 percent) but PPV decreased when ICD-9 410 was used in
combination with other codes (range: 19 90 percent) that were not
specific to AMI. NPV was only calculated in four studies (Kennedy,
Stern, and Crawford 1984; Palomaki et al. 1994; Pladevall et al. 1996;
Heckbert et al. 2004), where values ranged from 68.8 to 100 percent for
ICD-9 410 in isolation, and from 45.8 to 98.3 percent for ICD-9 410-411.

Literature Review of Case Definitions Used in AMI Studies

Sixty-three articles were identified, including eight studies from
Canada, six from Denmark, one from Italy, two from the Netherlands, one
from New Zealand, two from Scotland, two from Sweden, one from the
United Kingdom, and forty-one from the United States. Fifty-three
studies used ICD9 coding, all of which used some variation in ICD-9 code
410 to identify cases of AMI (see Table 3). Fifteen studies used ICD-10
codes, all of which used some variation in ICD-10 code I21 to identify
cases of AMI (see Table 3).

Validating AMI Case Definitions in Dually Coded ICD-9-CM and ICD-10
Hospital Discharge Data

Of the 4,008 charts reviewed, 169 indicated that the patient had
AMI resulting in a prevalence of 4.2 percent. All previously validated
case definitions had specificity values of at least 99 percent and NPV
86 percent or above; however, sensitivity ranged from 20.9 percent
(ICD-9 411) to 84.0 percent (ICD 9 410.x0, 410.x1) and PPV ranged from
13.6 percent (ICD-9 411) to 97.6 percent (ICD 9 410-414) (see Table 4).
Use of either ICD-9 410 or ICD-10 121-122 resulted in similar validity.

AMI Case Volume and In-Hospital Mortality in Hospital Discharge
Data

The eight previously validated case definitions were applied to
hospital discharge abstract data (n = 94,937 for ICD-9-CM, 2001/2002 and
n = 118,839 for ICD-10, 2006/2007) to assess their impact on number of
AMI cases and in-hospital mortality (Table 5). The ICD-9 code
combination 410-414 identified the greatest number of AMI cases in any
diagnostic field (n = 14,645) and in the primary diagnostic field (n =
3,581). The ICD-9 code 410, the most commonly validated AMI code in the
literature, identified 1,958 cases using all diagnostic fields and 1,488
cases using only the primary diagnostic field. In-hospital mortality
from validated case definitions ranged from 0 percent (ICD-9 411 used in
isolation and found in either the primary diagnostic field or any
diagnostic field) to 10.3 percent (ICD-9 410.0 used in isolation and
found in the primary diagnostic field). The mortality was 6.1 percent (n
= 91 deaths) among AMI cases identified using ICD-9 code 410 on the
primary diagnosis coding field, and 6.6 percent (n = 129 deaths) among
AMI cases using ICD-9 code 410 in any diagnostic coding fields.

Some component parts of various case definitions identified few
cases, but they had very high mortality rates. For example, when used in
the primary position, the ICD-9 code 427.5 (cardiac arrest) identified
nine hospitalized patients, but it was associated with a mortality rate
of 66.7 percent; the mortality rate for this code dropped to 19.2
percent when found in any diagnostic coding field. In other instances,
specific codes contributed very little to case definitions. For example,
the validated case definition ICD-10 I21 or I22 identified 1,425
admissions when either code was found in the primarily position, and
2,450 admissions when either code was found in any diagnostic coding
field; however, the ICD-10 code I22 only identified three admissions if
it was coded in the primary diagnostic coding field and seven admissions
if it was coded in any diagnostic coding field and no deaths (regardless
of coding field).

DISCUSSION

Through a systematic review of the literature, this study
identified eight validated AMI case definitions using hospital discharge
abstract data. These validated case definitions had varying ranges of
validity. Based on reported values for sensitivity, specificity, PPV,
and NPV, it appears that the three-digit ICD-9 code 410 (acute
myocardial infarction) used in isolation had the highest validity. When
these eight case definitions were validated in one dataset, ICD-9 410
still had high validity. Although a substantial amount of heterogeneity
was noted in the content of case definitions, which is reflected in the
variability of their performance characteristics, there is a substantial
amount of agreement with regard to case definitions that are used in the
published literature. An examination of ICD-9 and ICD-10 codes used in
the published literature revealed very few differences in the codes
used--all studies that used ICD-9 used some variation in code 410, while
all studies that used ICD-10 used some variation in ICD-10 code I21,
thus allowing for meaningful comparisons across studies. However, as
more countries transition from ICD-9 to ICD-10, the ICD-10-based case
definitions for AMI codes should be validated.

While the reasoning for the variation in reported values of
sensitivity and specificity for the same case definition is unclear, it
could be due to the underlying definition of AMI. Many studies included
ICD-9 code 411 (other acute and subacute forms of ischemic heart
disease) in their definition. As this code is not the correct assignment
of true AMI cases, its inclusion reduces the specificity of the case
definition. Inclusion of ICD-9 codes 412 (old myocardial infarction) and
413 (angina pectoris) in the case definition further reduces the
specificity of a case definition that aims to identify cases of acute
myocardial infarction as it mixes symptoms with disease and includes
conditions that are clinically distinct from AMI. Limiting the
administrative data case definition to codes found in the primary
diagnostic coding field can also impact the sensitivity and specificity
of reported definitions as codes in this position merely represent the
main reason for hospitalization or resource consumption, but they cannot
capture all health events that occurred in hospital or that motivated
hospital admission. Searching secondary code positions for codes of
interest will increase the sensitivity of a case definition. The
heterogeneity in the codes used to identify AMI may also reflect
underlying clinical uncertainty in the definition of AMI. Multiple
clinical diagnostics such as imaging, biochemistry, electrocardiography,
and pathology are used to clinically establish whether a patient
experienced an AMI (Thygesen et al. 2007). As the science of each of
these fields has advanced, clinicians have been able to more accurately
diagnosis AMI events; this is particularly true for biochemistry, as the
rapid introduction of new biomarkers in recent years, such as the
introduction of troponin as a biochemical marker of AMI, has increased
the clinical sensitivity and specificity of AMI diagnoses (Thygesen et
al. 2007). While changing clinical definitions of AMI are not currently
reflected in ICD codes, any clinical changes that improve the accuracy
of AMI diagnoses will impact the incidence and prevalence of this
condition when studied using administrative data.

Differences in the predictive ability of case definitions could
also be related to the gold standard used to confirm the AMI diagnosis
and the population studied. Studies have shown that accepting the
diagnosis coded in the chart at face value is not always valid (Iezzoni
et al. 1988; Hennessy et al. 2010). The use of clinical parameters in
the chart to assess for the presence or absence of AMI instead of
accepting the diagnosis as written in the chart likely increases the
sensitivity of the case definition. In addition, the source population
captured by the gold standard will influence the predictive ability of
case definitions. Patient registries will typically capture a different
population than that identified by general medical record review as
registries tend to focus on higher risk populations, thus artificially
increasing the sensitivity of a case definition as only the sickest
individuals are captured in the reference standard. The reporting of
PPV, in addition to sensitivity, can help overcome this limitation.

Also of note is the variation in health care systems across
countries with regard to coder variation (trained health coders vs.
physician coders) (Hennessy et al. 2010), the number of secondary
diagnoses allowed (World Health Organization 2010), and country-specific
modifications to ICD coding manuals (Jette et al. 2010; World Health
Organization 2010); all of these factors may impact the validity of case
definitions.

This study draws to light the differences in reporting practices
for validation studies and indicates the need for reporting guidelines
for this body of literature to enhance comparability between studies.
This study also calls into question what values of sensitivity and
specificity are required to call a case definition
"validated". While sensitivity and specificity values of
greater than 80 percent are considered excellent, sensitivity values as
low as 66 percent for AMI are found in the literature (Rosamond et al.
2004). While a specificity value below 80 percent was only found in one
study included in the review (Palomaki et al. 1994), only eight
(Kennedy, Stem, and Crawford 1984; Mascioli, Jacobs, and Kottke 1989;
Palomaki et al. 1994; Pladevall et al. 1996; McAlpine et al. 1998;
Newton et al. 1999; Austin, Daly, and Tu 2002; Heckbert et al. 2004) of
the 26 studies reported data on specificity.

While ICD-10 has been available for over 20 years (World Health
Organization 2010) and its coding descriptions dramatically changed
compared with ICD-9, no studies could be found that exclusively
validated ICD-10 codes for AMI. ICD-10 and ICD-9 specified AMI using
inconsistent duration from onset; the longer duration in ICD-9 than
ICD-10 (8 weeks or less vs. 4 weeks or less) might result in more AMIs
being coded in ICD-9 than ICD-10. In addition, the ICD-9 code 410 and
ICD-10 code I21 (AMI) are subdivided into transmural AMI and
nontransmural AMI; however, this subdivision is not defined by ST
segment elevation. Although modified versions of ICD-9-CM (Steinberg et
al. 2008) and ICD-10 Canadian modification have been developed to
distinguish between ST segment elevation myocardial infarction (STEMI)
and non-ST segment elevation myocardial infarction (NSTEMI), not all
countries make use of these modifications. The ICD-11 will specify STEMI
and NSTEMI.

This study has some limitations. The literature review was limited
to papers written in English only and validation studies published in
the gray literature were not included. Publication bias was not
specifically assessed; however, as several studies were identified with
low sensitivity, specificity, positive, and negative predictive values,
this is not believed to have substantially influenced the results. It is
possible that individual authors selectively reported only their best
case definition as opposed to all case definitions tested. As
inter-country differences exist in administrative coding practices
(Hennessy et al. 2010; Jette et al. 2010), it is also possible that the
results generated by applying the validated case definitions to Alberta
data may not be generalizable to other regions. Furthermore, as
2001-2002 was in the early phases of troponin use as a clinical
biomarker of AMI, the comparison of results from 2001/02 to 2006/07 is
likely to be influenced by changing clinical practices in addition to
changes in administrative data coding practices.

In conclusion, a variety of case definitions for AMI using
administrative data have been found in the literature, with variable
validity. While reporting guidelines for validation studies have
recently been released (Benchimol et al. 2011), their application is
essential to ensure comparability between studies and to ensure adequate
reporting of results. In addition, international consensus on what
constitutes an AMI and validation of ICD-10 codes for AMI is critically
needed as more countries introduce this coding framework for
epidemiological and outcomes study of AMI. We recommend ICD-9-CM code
410 and ICD-10 codes I21 and I22 in the primary diagnosis coding field
should be used to define AMI.

DOI: 10.1111/j.1475-6773.2012.01440.x

ACKNOWLEDGMENTS

Joint Acknowledgment/Disclosure Statement: Amy Metcalfe holds a
Canadian Institutes of Health Research Award in Genetics (Ethics, Law,
and Society) and a CIHR Strategic Training Program Studentship award in
Genetics, Child Development, and Health. Hude Quan holds a Senior
Scholar award from Alberta Innovates Health Solutions (AIHS). Nathalie
Jette holds a New Investigator Award from AIHS and a Canada Research
Chair Tier 2 in

Neurological Health Services Research. Please refer to SA1 for
additional information.

Disclaimers: None.

Disclosures: None.

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SUPPORTING INFORMATION

Additional supporting information may be found in the online
version of this article:

Appendix SA1: Author Matrix.

Please note: Wiley-Blackwell is not responsible for the content or
functionality of any supporting materials supplied by the authors. Any
queries (other than missing material) should be directed to the
corresponding author for the article.

Address correspondence to Amy Metcalfe, M.Sc., Departments of
Community Health Sciences and Clinical Neurosciences, University of
Calgary, TRW Building, 3rd Floor, 3280 Hospital Drive NW, Calgary, AB,
Canada T2N 4Z6; e-mail: amy.metcalfe@albertahealthservices.ca. Annabelle
Neudam, M.Sc., and Saskia Drosler, M.D., are with the Niederrhein
University of Applied Sciences, Reinarzstr. Krefeld, Germany. Samantha
Forde, B.HSc., is with the Department of Clinical Neurosciences,
University of Calgary, Calgary, AB, Canada. Mingfu Liu, Ph.D., is with
the Data Integration, Measurement and Reporting, Alberta Health
Services, Calgary, AB, Canada. Hude Quan, M.D., Ph.D., is with the
Department of Community Health Sciences, University of Calgary, Calgary,
AB, Canada. Nathalie Jette, M.D., M.Sc., is with the Departments of
Clinical Neurosciences and Community Health Sciences, University of
Calgary, Calgary, AB, Canada.

Table 1: International Classification of Disease (ICD) Codes Used
as Part of Validated Acute Myocardial Infarction  Case
Definitions

ICD-9-CM   Definition
Code

410        Acute myocardial infarction
410.x0     Acute myocardial infarction: episode of care unspecified
410.x1     Acute myocardial infarction: initial episode of care
410.0      Acute myocardial infarction of anterolateral wall
410.1      Acute myocardial infarction of other anterior wall
410.2      Acute myocardial infarction of inferolateral wall
410.3      Acute myocardial infarction of inferoposterior wall
410.4      Acute myocardial infarction of other inferior wall
410.5      Acute myocardial infarction of other lateral wall
410.6      True posterior wall infarction
410.7      Subendocardial infarction
410.8      Acute myocardial infarction of other specified sites
             (infarction of atrium, papillary muscle, septum alone)
410.9      Acute myocardial infarction: unspecified site
411        Other acute and subacute forms of ischemic heart disease
412        Old myocardial infarction
413        Angina pectoris
414        Other forms of chronic ischemic heart disease
427.4      Ventricular fibrillation and flutter
427.5      Cardiac arrest

ICD-9-CM     ICD-10-CA           Definition
Code           Code

410             121      Acute myocardial infarction
410.x0          122      Subsequent myocardial
                           infarction
410.x1          --                   --
410.0           --                   --
410.1           --                   --
410.2           --                   --
410.3           --                   --
410.4           --                   --
410.5           --                   --
410.6           --                   --
410.7           --                   --
410.8           --                   --

410.9           --                   --
411             --                   --
412             --                   --
413             --                   --
414             --                   --
427.4           --                   --
427.5           --                   --

Table 2: Validation Studies and Results until july 2010

                                                     Year of Data
Author                  Country            N          Collection

Austin, Daly,       Canada            58,816         Jan 1996-Mar
  and Tu (2002)                                        2000
Beaglehole,         New Zealand       858            1983
  Stewart, and
  Walker (1987)
Boyle and           Australia         5,283          Aug 1986-
  Dobson (1995)                                        33573
Dobson et al.       Australia         2,947          1979,1984-
  (1988)                                               1985

Ellerbeck           USA               14,108         June 1992-
  et al. (1995)                                        34001
Fisher et al.       USA               Any: 271       Oct 1984-
  (1992)                                Principle:     31107
                                        204

Hammar              Sweden            713            1987-1995
  et al. (2001)
Heckbert            USA               1,042          Jan 1994-Nov
  et al. (2004)                                        2000

Kennedy,            USA               20,386         12-month
  Stern, and                                           period
  Crawford                                             before 1984
  (1984)
Kiyotaet al.        USA               2,022          1999.2
  (2004)

Levy et al-         Canada            234            1994
  (1!)9i))
Lindblad et al.     Sweden            432            1977-1987
  (1993)
Mahonen et al.      Finland           397            1983-1990
  (1997)

Mascioli,Jacobs,    USA               1,845          Jan-June 1979
  and Kottke
  (1989)
McAlpine et al.     Scotland          154            Oct 1993-Oct
  (1998)                                               1995

Merry et al.        The Netherlands   21,110         1987-1997
  (2009)
Newton et al.       USA               121            Jan 1992-Mar
  (1999)                                               1996
Nova Scotia-        Canada            410:1,810      1977-1985
  Saskatchewan                          411-414:
  Cardiovascular                        1059
  Disease
  Epidemiology
  Group (1992)
Pajunen et al.      Finland           37,062         1988-2002
  (2005)                                CHD
                                        events
Palomaki et al.     Finland           1,565          1987-1990
  (1994)

Petersen et al.     USA               4,565          Jan 1994-Sep
  (1999)                                               1995
Pladevall et al.    USA               734            May 1988-
  (1996)                                               Apr 1990
Rosamond et al.     USA               17,900         1987-2000
  (2004)
Ryu et al. (2000)   Korea             258            1993-1997

Varas-Lorenzo       Canada            ICD 9 code     Nov 1999-
  et al. (2008)                         410:193        Dec 2001
                                      ICD-9 code
                                        411:763
Yeh et al. (2010)   USA               640            1999-2007

                     Administrative       Gold          ICD
Author                  Database        Standard       Code *

Austin, Daly,       Hospital           Registry     410
  and Tu (2002)       discharge          data
Beaglehole,         Hospital           Registry     410
  Stewart, and        discharge          data       410-414
  Walker (1987)
Boyle and           Hospital           Registry     410
  Dobson (1995)       discharge          data
Dobson et al.       Hospital           Registry     410
  (1988)              discharge          data
                                                    410-414

Ellerbeck           Hospital           Chart        410
  et al. (1995)       discharge          review
Fisher et al.       Hospital           Chart        410
  (1992)              discharge          review

Hammar              Hospital           Chart        410
  et al. (2001)       discharge          review
Heckbert            Hospital           Chart        410,
  et al. (2004)       discharge          review       427.4,
                                                    427.5

Kennedy,            Hospital           Registry     410
  Stern, and          discharge          data
  Crawford
  (1984)
Kiyotaet al.        Hospital           Chart        410.x0410.x1
  (2004)              discharge          review

Levy et al-         Hospital           Chart        410
  (1!)9i))            discharge          review
Lindblad et al.     Hospital           Chart        410-411
  (1993)              admissions         review
Mahonen et al.      Hospital           Registry     410
  (1997)              discharge          data
                                                    410-411

Mascioli,Jacobs,    Hospital           Chart        410-411
  and Kottke          discharge          review     412-414
  (1989)
McAlpine et al.     Hospital           Chart        410
  (1998)              discharge          review     411
                                                    413
                                                    414

Merry et al.        Hospital           Registry     410
  (2009)              discharge          data
Newton et al.       Hospital data      Chart        410, 427.4,
  (1999)                                 review       427.5
Nova Scotia-        Hospital           Chart        410
  Saskatchewan        discharge          review     411-414
  Cardiovascular
  Disease
  Epidemiology
  Group (1992)
Pajunen et al.      Hospital           Chart        410,121,
  (2005)              discharge          review     122

Palomaki et al.     Hospital           Registry     410
  (1994)              discharge          data       410.0-410.9
                                                    410, 411
Petersen et al.     Hospital           Chart        410
  (1999)              discharge          review
Pladevall et al.    Hospital           Registry     410
  (1996)              discharge          data       410-411
Rosamond et al.     Hospital           Chart        410
  (2004)              Discharge          review
Ryu et al. (2000)   Hospital           Chart        410
                      discharge          review

Varas-Lorenzo       Hospital           Chart        410
  et al. (2008)       discharge          review     411

Yeh et al. (2010)   Hospital           Chart        410.x0,
                      discharge          review     410.x1

                      Sensitivity        Specificity
Author                    (%)                (%)

Austin, Daly,       MRD: 88.8          MRD: 92.8
  and Tu (2002)     Any: 92.8          Any: 89.2
Beaglehole,         86.0               --
  Stewart, and      95.1               --
  Walker (1987)
Boyle and           78.9               --
  Dobson (1995)
Dobson et al.       84.8 (1979)        --
  (1988)            84.8 (1984)
                    78.6 (1979)        --
                    91.6 (1984)
Ellerbeck           --                 --
  et al. (1995)
Fisher et al.       Any diagnostic     --
  (1992)              field: 90.0
                    Primary
                      diagnostic
                      field: 94.0

Hammar              94                 --
  et al. (2001)
Heckbert            80                 99.4 ([dagger])
  et al. (2004)

Kennedy,            94.3               99.8
  Stern, and
  Crawford
  (1984)
Kiyotaet al.        --                 --
  (2004)

Levy et al-         --                 --
  (1!)9i))
Lindblad et al.     --                 --
  (1993)
Mahonen et al.      Men: 86.0          --
  (1997)            Women: 81.3
                    Men: 79.6          --
                    Women: 73.9
Mascioli,Jacobs,    84.7               92.8
  and Kottke        --                 --
  (1989)
McAlpine et al.     67.0               100.0
  (1998)            5.6                99.0
                    5.6                94.0
                    5.6                86.0

Merry et al.        84.0               --
  (2009)
Newton et al.       94.4               86.4
  (1999)
Nova Scotia-        --                 --
  Saskatchewan      --                 --
  Cardiovascular
  Disease
  Epidemiology
  Group (1992)
Pajunen et al.      83.0               --
  (2005)

Palomaki et al.     88.7 ([dagger])    93.8 ([dagger])
  (1994)            72.3 ([dagger])    90.6 ([dagger])
                    71.0 ([dagger])    74.9 ([dagger])
Petersen et al.     --                 --
  (1999)
Pladevall et al.    80.9               93.1
  (1996)            86.5               80.2
Rosamond et al.     Men: 69.0          --
  (2004)            Women: 66.0
Ryu et al. (2000)   --                 --

Varas-Lorenzo       --                 --
  et al. (2008)     --                 --

Yeh et al. (2010)   --                 --

                          PPV               NPV
Author                    (%)               (%)

Austin, Daly,       MRD: 88.5
  and Tu (2002)     Any: 84.2
Beaglehole,         67.1              --
  Stewart, and      25.6 ([dagger])   --
  Walker (1987)
Boyle and           65.6              --
  Dobson (1995)
Dobson et al.       79.3 (1979)       --
  (1988)            70.2 (1984)
                    67.9 (1979)       --
                    42.7 (1984)
Ellerbeck           87.4
  et al. (1995)
Fisher et al.       Any               --
  (1992)              diagnostic
                      field: 87.0
                    Primary
                      diagnostic
                      field: 92.0
Hammar              86                --
  et al. (2001)
Heckbert            77.7              99.5 ([dagger])
  et al. (2004)

Kennedy,            60.9              100
  Stern, and
  Crawford
  (1984)
Kiyotaet al.        Any               --
  (2004)              diagnostic
                      field: 94.1
                    Primary
                      diagnostic
                      field: 95.1
Levy et al-         96.0              --
  (1!)9i))
Lindblad et al.     91.4 ([dagger])   --
  (1993)
Mahonen et al.      Men: 85.9         --
  (1997)            Women: 80.7
                    Men: 84.8         --
                    Women: 79.0
Mascioli,Jacobs,    94.6              --
  and Kottke        18.8              --
  (1989)
McAlpine et al.     100.0             --
  (1998)            50.0              --
                    9.1               --
                    4.5               --

Merry et al.        97.0              --
  (2009)
Newton et al.       56.8              --
  (1999)
Nova Scotia-        8.5.5 ([dagger])  --
  Saskatchewan      7.1 ([dagger])    --
  Cardiovascular
  Disease
  Epidemiology
  Group (1992)
Pajunen et al.      90.0              --
  (2005)

Palomaki et al.     86.4 ([dagger])   92.4 ([dagger])
  (1994)            92.0 ([dagger])   68.8 ([dagger])
                    89.6 ([dagger])   45.8 ([dagger])
Petersen et al.     96.9              --
  (1999)
Pladevall et al.    54.6              97.9
  (1996)            31                98.3
Rosamond et al.     Men: 58.0         --
  (2004)            Women: 52.0
Ryu et al. (2000)   76                --

Varas-Lorenzo       94.8 ([dagger])   --
  et al. (2008)     8.7 ([dagger])    --

Yeh et al. (2010)   96.7              --

* All are ICD-9 codes except for 121 and 122, which are
ICD-10 codes.

([dagger]) Derived values.

AMI, acute myocardial infarction; CHD, coronary heart disease;
MRD, most responsible diagnosis; NPV, negative predictive value;
PPV, positive predictive value.

Table 3: Case Definitions of Acute Myocardial Infarction Commonly
Used  in the Literature (2007-2012)

Author                       Country             Study Years

Agyemang et al. (2009)       The Netherlands     1995
Berger et al. (2008)         USA                 2001
Brown, Xie,                  USA                 2003-2004
  and Mensah (2007)
Buch et al. (2007)           Denmark             1994-2002
Chan et al. (2008)           New Zealand         1993-2005
Chen et al. (2010)           USA                 2002-2007
Curtis et al. (2009)         USA                 2005
Dudas et al. (2011)          Sweden              1991-2006
Ezekowitz et al. (2009)      Canada              1994-2005
Fazel et a1. (2009)          USA                 2000-2006
Friberg et al. (2009)        Sweden              2002
Garget al. (2008)            USA                 2003-2004
Habel et al. (2011)          USA                 1986-2005
Hammill et al. (2009)        USA                 1999-2006
Ho et al. (2008)             USA                 2003-2005
Hvelplund et al. (2010)      Denmark             2005-2007
Jackevicius, Li,             Canada              1999-2001
  and Tu (2008)
Jensen et al. (2010)         Denmark             2002-2005
Joynt et al. (2011a)         USA                 2009
Joynt, Orav, and             USA                 2006-2009
Jha (2011b)
Khan et a1. (2010)           Canada              1994-2003
King, Khan, and              Canada              2002-2006
  Quan (2009)
Ko et al. (2007)             Canada and USA      1998-1999
Ko et al. (2008)             USA                 1998-2001
Kosiborod et al. (2008)      USA                 2000-2005
Kosiborod et al. (2009)      USA                 2000-2005
Kostiis et a1. (2007)        USA                 1987-2005
Krumholz et al. (2009)       USA                 1995-2006
Kulik et al. (2010)          USA                 1995-2004
Lambert et al. (2010)        Canada              2006-2007
Lipscombe et al. (2007)      Canada              2002-2005
Mauri et a1. (2008)          USA                 2003-2004
Mazzini et al. (2008)        USA                 2002-2003
McAlister et al. (2008)      Canada              1994-2000
McNamaraet al. (2007)        USA                 1999-2002
Mehta et al. (2010)          USA                 Not stated
Mehta et a1. (2008)          USA                 2000-2008
Movahed et al. (2009)        USA                 1998-2004
Nallamothu et al. (2007a)    USA                 2003
Nallamothu et al. (2007b)    USA                 2002-2005
Pearte et al. (2008)         USA                 1987-2001
Popescu, Cram, and           USA                 2005
  Vaughan-Sarrazin (2011)
Popescu,                     USA                 2000-2005
Vaughan-Sarrazin,
  and Rosenthal (2007)
Roger et al. (2010)          USA                 1987-2006
Ross et al. (2010)           USA                 2004-2006
Saia et al. (2009)           Italy               2002.2004
SchjerningOlsen              Denmark             1997-2006
  et al. (2011)
Sekhri et al. (2007)         United Kingdom      2003-2005
Setoguchi et al. (2007)      USA                 1995-2004
Setoguchi et al. (2008a)     USA                 1995-2004
Setoguchi et al. (2008b)     USA                 1999-2000
Shen and Hsia (2011)         USA                 2000-2006
Shreibati, Baker, and        USA                 2005-2008
  Hlatky (2011)
Sorensen et al. (2011)       Denmark             2002-2008
Sorensen et al. (2009)       Denmark             2000-2005
Suaya et al. (2007)          USA                 1997
Taylor et al. (2008)         Scotland            1996-2000
Towfighi, Markovic,          USA                 1997-2006
  and Ovbiagele (2011)
van der Elst et al. (2007)   The Netherlands     1991-2000
Volpp et al. (2007a)         USA                 2000-2005
Volpp et al. (2007b)         USA                 2000-2005
Wei et al. (2008)            Scotland            1994-2003
Yeh et al. (2010)            USA                 1999-2008

                                                 ICD-10
                             ICD-9 Case          Case
Author                       Definition          Definition

Agyemang et al. (2009)       410
Berger et al. (2008)         410
Brown, Xie,                  410
  and Mensah (2007)
Buch et al. (2007)                               121,122
Chan et al. (2008)           410                 121
Chen et al. (2010)           410.x0, 410.x1
Curtis et al. (2009)         410.x0, 410.x1
Dudas et al. (2011)          410                 121
Ezekowitz et al. (2009)      410
Fazel et a1. (2009)          410.x1
Friberg et al. (2009)                            121
Garget al. (2008)            410.x1
Habel et al. (2011)          410                 121,122
Hammill et al. (2009)        410.x1
Ho et al. (2008)             410
Hvelplund et al. (2010)                          121,122
Jackevicius, Li,             410
  and Tu (2008)
Jensen et al. (2010)                             121
Joynt et al. (2011a)         410.x0, 410.x1
Joynt, Orav, and             410.x0, 410.x1
Jha (2011b)
Khan et a1. (2010)           410
King, Khan, and                                  121,122
  Quan (2009)
Ko et al. (2007)             410
Ko et al. (2008)             410
Kosiborod et al. (2008)      410.x0, 410.x1
Kosiborod et al. (2009)      410.x0, 410.x1
Kostiis et a1. (2007)        410
Krumholz et al. (2009)       410.x0, 410.x1
Kulik et al. (2010)          410.x1, 411
Lambert et al. (2010)        410
Lipscombe et al. (2007)      121,124,125.4
Mauri et a1. (2008)          410.x1
Mazzini et al. (2008)        410
McAlister et al. (2008)      410
McNamaraet al. (2007)        410.x1
Mehta et al. (2010)          410
Mehta et a1. (2008)          410
Movahed et al. (2009)        410.01, 410.11,
                               410.21, 410.31,
                               410.41, 410.51,
                               410.61, 410.81
Nallamothu et al. (2007a)    410.x0, 410.x 1
Nallamothu et al. (2007b)    410.x1
Pearte et al. (2008)         402,410-414,
                             427,428,518.4
Popescu, Cram, and           410
  Vaughan-Sarrazin (2011)
Popescu,                     410
Vaughan-Sarrazin,
  and Rosenthal (2007)
Roger et al. (2010)          410
Ross et al. (2010)           410.x0, 410.xl
Saia et al. (2009)           410
SchjerningOlsen                                  121,122
  et al. (2011)
Sekhri et al. (2007)                             121-123
Setoguchi et al. (2007)      410
Setoguchi et al. (2008a)     410
Setoguchi et al. (2008b)     410
Shen and Hsia (2011)         410.x0, 410.x1
Shreibati, Baker, and        410.x
  Hlatky (2011)
Sorensen et al. (2011)                           121,122
Sorensen et al. (2009)                           121,122
Suaya et al. (2007)          410
Taylor et al. (2008)         410                 121,122
Towfighi, Markovic,          410.x0, 410.x1
  and Ovbiagele (2011)
van der Elst et al. (2007)   410
Volpp et al. (2007a)         410.00-410.19,
                             410.20-410.69,
                             410.7x,
                             410.80-410.99
Volpp et al. (2007b)         410.00-410.19,
                             410.20-410.69,
                             410.7x,
                             410.80-410.99
Wei et al. (2008)            410                 121
Yeh et al. (2010)            410.x0, 410.x1

Table 4: Validation of International Disease Classification (ICD)
Hospital Discharge Abstract Data Based on Chart Review Data for
Acute Myocardial Infarction

                                                 Positive    Negative
                      Sensitivity  Specificity  Predictive  Predictive
Case Definition           (%)          (%)      Value (%)   Value (%)

ICD-9-CM
  410                    83.3         99.2         82.8        99.3
  410.x0, 410.x1         84.0         99.2         81.1        99.3
  410411                 56.5         99.4         87.0        97.1
  410-414                24.2         99.9         97.6        86.5
  410, 427.4, 427.5      73.1         99.3         83.4        98.6
  411                    20.9         96.3         13.6        97.7
  411-414                22.7         99.4         87.6        86.8
ICD-10
  I21, I22               81.8         99.2         82.2        99.2

Table 5: Acute Myocardial Infarction (AMI) Case Volume and In-Hospital
Deaths by Case Definition

                                      AMI
                                    Defined
                                     Using
                                    Primary     Number    Death
                                   Diagnosis   of Death    Rate
ICD Codes                             (A)        (B)      (A/B%)

Year 2001/2002 (ICD-9-CM)
                        410            1,488         91      6.1
  ICD-9-CM            410.x0,          1,477         91      7.0
    case                410,x1
    definitions       410,411          1,621         91      5.6
                      410114           3,581        111      3.1
                      410, 4274,       1,515        100      6.6
                        427.5
                      411                130          0      0.0
                      411-414          1,961         20      1.0
  Relative            410.x0              11          2     18.2
    contribution      410.x 1          1,466         89      6.1
    of each code      410.0               68          7     10.3
    to ICD-9-CM       410.1              249         23      9.2
    case              410.2               57          7     12.3
    definitions       410.3               65          3      4.6
                      410.4              285          8      2.8
                      410.5               26          1      3.8
                      410.6                7          0      0.0
                      410.7              566         19      3.4
                      410.8               14          3     21.4
                      410.9               53         14     26.4
                      412                  0          0      0.0
                      413                 76          0      0.0
                      414              1,755         20      1.1
                      427.4               17          3     17.6
                      427.5                9          6     66.7
Year 2006/2007 (ICD-10)
  ICD-10 case         121,122          1,425         94      6.6
    definition
  Relative            121              1,422         94      6.6
    contribution
    of each code to
    ICD-10 case
    definition        122                  3          0      0.0

                                      AMI
                                    Defined
                                     Using
                                    Primary
                                      and
                                   Secondary    Number     Death
                                   Diagnosis   of Death    Rate
ICD Codes                             (C)        (D)      (C/D %)

Year 2001/2002 (ICD-9-CM)
                        410            1,958        129       6.6
  ICD-9-CM            410.x0,          1,855        129       7.0
    case                410,x1
    definitions       410,411          3,352        129       3.8
                      410114          14,645        219       1.5
                      410, 4274,       2,322        143       6.2
                        427.5
                      411              1,306          0       0.0
                      411-414         11,974         88       0.7
  Relative            410.x0              17          2      11.8
    contribution      410.x 1          1,838        127       6.9
    of each code      410.0               75          7       9.3
    to ICD-9-CM       410.1              303         24       7.9
    case              410.2               65          7      10.8
    definitions       410.3               77          3       3.9
                      410.4              331         14       4.2
                      410.5               41          2       4.8
                      410.6               12          0       0.0
                      410.7              744         29       3.9
                      410.8               26          3      11.5
                      410.9              167         33      19.8
                      412              2,637          9       0.3
                      413              1,271          3       0.2
                      414              6,760         76       1.1
                      427.4              119          0       0.0
                      427.5              224         43      19.2
Year 2006/2007 (ICD-10)
  ICD-10 case         121,122          2,450        186       7.6
    definition
  Relative            121              2,443        186       7.6
    contribution
    of each code to
    ICD-10 case
    definition        122                  7          0       0.0

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