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Is There More Than Meets the I(CD Code)? The Corpus Christi Heart Project

David C. Goff, Jr, MD, PhD; Dilip K. Pandey, MD, PhD; Frances A. Chan, MPH; Carmen Ortiz; Milton Z. Nichaman, MD, ScD

Arch Intern Med. 2000;160:197-202.

Background  Congestive heart failure (CHF) is increasing as a public health problem in the United States. The ability to quantify this problem has been limited by a lack of data regarding the validity of CHF identification.

Objective  To assess the validity of the use of International Classification of Diseases, Ninth Revision, Clinical Modification (ICD) codes to identify hospitalizations with clinical evidence of an episode of acute CHF in data of The Corpus Christi Heart Project, a population-based surveillance program for hospitalized coronary heart disease.

Methods  The validation standard was a composite variable including the presence of physician diagnosed acute CHF or radiographic evidence of pulmonary edema. Data were abstracted from the medical records of 5083 patients identified as hospitalized for possible acute myocardial infarction, aortocoronary bypass surgery, percutaneous transluminal coronary angioplasty, and related revascularization procedures in the Corpus Christi Heart Project. Discharge diagnoses, a secondary source of data, were used to apply 3 computer algorithms to assess the assignment of ICD codes.

Results  The prevalence of clinically documented CHF was 27.1% (1376/5083). The ICD code 428 (CHF), assigned as the primary or a secondary discharge diagnosis, was associated with 62.8% sensitivity, 95.4% specificity, 83.5% positive predictive value, 87.4% negative predictive value, and a 24.8% underenumeration of CHF-related hospitalizations. An algorithm based on a series of ICD codes was associated with 67.1% sensitivity, 92.6% specificity, 77.1% positive predictive value, 88.3% negative predictive value, and a 13.0% underenumeration of CHF-related hospitalizations.

Conclusions  Reliance on ICD codes results in the exclusion of one third of the patients with clinical evidence of acute CHF. This underenumeration is compounded by the typical reliance on the first listed diagnosis. Congestive heart failure may be a greater public health problem than currently recognized. The allocation of resources for relevant surveillance, research, medical care, and preventive efforts should be reevaluated.

From the Departments of Public Health Science and Internal Medicine, Wake Forest University School of Medicine (Dr Goff); and the Epidemiology Research Center, University of Texas–Houston Health Science Center School of Public Health (Drs Pandey and Nichaman and Mss Chan and Ortiz).

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